Introduction to current issues on HIV/AIDS in older adults
By Timothy G. Heckman, PhD
Through 2012, more than 1.1 million Americans had been diagnosed with AIDS (CDC, 2012). Of these, 155,642 (13.8 percent) were 50 years of age or older at the time of their AIDS diagnosis. In 2009, the prevalence rate of persons living with a diagnosis of HIV infection who were 50-54 (568/100,000) or 55-59 years of age (409/100,000) actually exceeded that of persons living with HIV infection who were 30-34 years old (336/100,000; CDC, 2012). Because of continuing risky sexual behaviors in HIV-infected older adults (Illa et al., 2008; Lovejoy et al., 2008) and extended survival periods due to increasingly efficacious antiretroviral therapies and improved clinical care (Palella et al., 2006), it is anticipated that one out of every two people living with HIV/AIDS in the United States in 2015 will be 50 years of age or older (Justice, 2010).
The growing number of older adults living with HIV/AIDS is not unique to the United States; indeed, it is an international dilemma. In Nanning, China, the proportion of people living with HIV/AIDS who were 50 or older increased from 16.5 percent in 2007 to 42.7 percent in 2011 (Liu, Lin, Xu, Chen, Shi & Morisky). In Madagascar, persons ≥ 50 account for 34.9 percent of all HIV infections in the country (Negin & Cumming, 2010). In Zambia, persons ≥ 50 account for 20.4 percent of all HIV infections (Negin & Cumming, 2010). Clearly, the “graying” of HIV knows no geographic boundaries.
The mental health needs of older adults living with HIV/AIDS are multi-faceted and ever-evolving (Martin et al., 2008). HIV-positive older adults are five times more likely to experience depression than similarly-aged HIV-negative adults (Applebaum & Brennan, 2009). Kalichman et al. (2000) found that 27 percent of HIV-infected older adults had thought about suicide in the previous week. Grov et al. (2010) found that 39 percent of community-dwelling HIV-infected older adults exhibited symptoms of major depressive disorder. Elevated levels of depressive symptoms in HIV-infected older adults are troubling because of their associations with poor life quality, impaired daily functioning, increased frailty, poor engagement and retention in care, and a greater number of comorbid health conditions (Havlik et al., 2009; High et al., 2012; Negin et al., 2012).
Compared to their younger counterparts, HIV-infected older adults have significantly lower CD4 cell counts, higher plasma viral loads at the time of their HIV-serostatus identification and a lower likelihood of survival after an AIDS diagnosis (CDC, 2011; Martin et al., 2008). HIV-infected older adults also have fewer social supports, lower rates of HIV-serostatus disclosure and experience a large number of AIDS-related bereavements (Emlet, 2006; Rabkin et al., 2004; Siegel et al., 1999). In light of the many psychosocial challenges that HIV-infected older adults experience, it is very troubling that HIV-infected older adults are less likely to seek treatment for psychological disorders (Zanjani et al., 2007). Moreover, there are currently no-age contextualized mental health interventions for HIV-infected older adults that promote clinically meaningful and sustained reductions is psychiatric symptoms.
This issue of the Psychology and AIDS Exchange Newsletter provides researchers, practitioners, policy makers and caregivers with an update on the biopsychosocial needs of persons aging with HIV. The current convention is to define HIV-infected older adults as persons living with HIV/AIDS who are 50 years of age or older. While there is nothing particularly remarkable about the age cutoff of 50 years, 50 years of age is used by many organizations to classify adults as “older” (e.g., the World Health Organization and Centers for Disease Control and Prevention). Moreover, Egger et al. (2002) identified ≥ 50 years old as an independent prognostic factor affecting clinical progression to AIDS and death. Many articles in this issue use ≥ 50 years of age as the cutoff for older adults.
In the current issue, several prominent researchers and practitioners address fundamental issues central to the lives of older adults living with HIV/AIDS. Travis Lovejoy, PhD, summarizes the still scant literature on patterns and predictors of continued unsafe sex in HIV-infected older adults and addresses potential intervention approaches to reduce risky sex in this group. Charles Emlet, PhD, LCSW, ACSW, discusses how stigmas related to HIV and aging impact the lives of many HIV-infected older adults. Stephen Karpiak, PhD, summarizes the literature on rates of adherence to HIV medications in HIV-infected older adults and the plethora of factors that influence adherence in this group. Richard Havlik, MD, MPH, discusses an increasingly problematic issue that affects a large number of HIV-infected older adults; the prevalence and impact of comorbid health conditions, such as depression, cardiovascular heart disease, osteoarthritis and cancer. Finally, Miranda and colleagues discuss race-related disparities in HIV-associated neurocognitive disorders in older adults living with HIV/AIDS.
Applebaum, A.B. & Brennan, M. "Mental Health and Depression," in Brennan, M., Karpiak, S.E., Cantor, M.H. & Shippy, R.A., eds., Older Adults with HIV: An In-Depth Examination of an Emerging Population. New York: Nova Publishers, 2009, 38-47.
Centers for Disease Control and Prevention. HIV Surveillance Report, 2011; vol. 23. p. 49. Published February 2013. Accessed [5/13/2013].
Centers for Disease Control and Prevention. HIV Surveillance Report, 2012. [serial online] 22, Accessed April 2, 2012.
Egger, M.E., May, M., Chene, G., Phillips, A.N. et al. (2002). Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: A collaborative analysis of prospective studies. Lancet, 360, 119-129.
Emlet, C.A. (2006). “You’re awfully old to have this disease:” Experiences of stigma and ageism in adults 50 years and older living with HIV/AIDS. Gerontologist, 46, 781-90.
Grov, C., Golub, S.A., Parsons, J.T., Brennan, M., & Karpiak, S.E. (201). Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care, 22, 630-9.
Havlik, R.J., Brennan, M., & Karpiak, S.E. (2011). Comorbidities and depression in older adults with HIV. Sexual Health, 8, 551.
High, K.P., Brennan-Ing, M., Clifford, D.B., Cohen, M., H., Currier, J. et al. (2012). HIV and aging: State of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group. Journal of Acquired Immune Deficiency Syndromes, 60, Supp. 1, S1-S18.
Illa, L., Brickman, A., Saint-Jean, G., Echenique, M., Metsch, L., et al. (2008). Sexual risk behaviors in late middle-age and older HIV-seropositive adults. AIDS and Behavior, 12, 935-942.
Justice, A. (2010). HIV and aging: Time for a new paradigm. Current HIV/AIDS Reports. 7, 69-76.
Kalichman, S.C., Heckman, T.G., Kochman, A.R., Sikkema, K.J., & Bergholte, J. (2000). Suicidal ideation among midlife and older adults living with HIV/AIDS. Psychiatric Services, 51, 903-907.
Liu, H., Lin, X., Xu, Y., Chen, S., Shi, J., & Morisky, D. (2012). Emerging HIV epidemic among older adults in Nanning China. AIDS Patient Care and STDs, 10, 565-567.
Lovejoy, T.I., Heckman, T.G., Sikkema, K.J., Hansen, N.B., Kochman, A., Suhr, J.A., Garske, J.P., & Johnson, C. J. (2008). Patterns and correlates of sexual activity and condom use in persons 50-plus years of age living with HIV/AIDS. AIDS and Behavior, 12, 943-956.
Martin, C.P., Fain, M.J., & Klotz, S.A. (2008). The older HIV-positive adult: A critical review of the medical literature. American Journal of Medicine, 121, 1032-1037
Negin, J. & Cumming, R.G. (2010). HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data. Bulletin of the World Health Organization, 88, 847-853.
Negin, J., Martiniuk, A., Cumming, R.G., Naidoo, N., Phaswana-Mafuya, N., Madurai, L., Williams, S., & Kowal, P, (2012). Prevalence of HIV and chronic comorbidities among older adults. AIDS, 26 (Suppl 1) , S55-63.
Palella. F.J., Baker, R.K., Moorman, A.C. et al. (2006). Mortality in the highly active antiretroviral therapy era: Changing causes of death and disease in the HIV Outpatient study. Journal of Acquired Immune Deficiency Syndromes, 43, 27-34.
Rabkin, J.G., McElhiney, M.C., & Ferrando, S.J. (2004). Mood and substance use disorders in older adults with HIV/AIDS: Methodological issues and preliminary evidence. AIDS, 18 (Suppl 1), S43-S48.
Siegel, K., Schrimshaw, E.W., & Dean, L. (1999). Symptom interpretation and medication adherence among late middle-age and older HIV-infected adults. Journal of Health Psychology, 4, 247-257.
Zanjani, F., Saboe, K., & Oslin, D. (2007). Age differences in rates of mental health /substance abuse. AIDS Patient Care and STDs. 21, 347-355.
About the Author
Timothy G. Heckman, PhD, is professor of health promotion and behavior, and associate dean for research in the college of public health at the University of Georgia. His research focuses on the use of telephones and innovative technologies to improve life quality in persons living with HIV/AIDS, with a particular focus on HIV-infected older adults and persons living with HIV/AIDS in small towns and rural communities. His AIDS mental health research has been funded by the National Institute of Mental Health, the National Institute on Aging and the National Institute of Nursing Research. Since 2000, he has served on numerous NIH study sections and currently serves as a member of the American Psychological Association’s Committee on Psychology and AIDS (COPA). He is a research fellow in the Rural Center for AIDS Prevention at Indiana University and an external collaborator with Northwestern University’s Center for Behavioral Intervention Technologies. He serves as associate editor for Behavioral Medicine, is on the editorial board of AIDS and Behavior, and has authored more than 70 peer-reviewed scientific manuscripts, which have appeared in journals such as the American Journal of Public Health, Health Psychology, Journal of Consulting and Clinical Psychology, and Journal of Acquired Immune Deficiency Syndromes. Heckman received his PhD in experimental psychology from the University of Vermont and his BA in psychology from Penn State University.