HIV and Aging: Double Stigma

Age-associated dementia among older people aging with HIV in the United States: a modeling study

OBJECTIVE

Almost 400 000 people with HIV (PWH) in the United States are over age 55 years and at risk for age-associated dementias (AAD), including Alzheimer's disease and vascular contributions to cognitive impairment and dementia (VCID). We projected the cumulative incidence and mortality associated with AAD among PWH at least 60 years in the United States compared with the general population.

DESIGN/METHODS

Integrating the CEPAC and AgeD-Pol models, we simulated two cohorts of 60-year-old male and female individuals: PWH, and the general US population. We estimated AAD incidence and AAD-associated mortality rates. Projected outcomes included AAD cumulative incidence, life expectancy, and quality-adjusted life-years (QALYs). We performed sensitivity and scenario analyses on AAD-specific (e.g. incidence) and HIV-specific (e.g. disengagement from HIV care) parameters, as well as premature aging among PWH.

RESULTS

We projected that 22.1%/16.3% of 60-year-old male individuals/female individuals with HIV would develop AAD by 80 years compared with 15.9%/13.3% of male individuals/female individuals in the general population. Accounting for age-associated and dementia-associated quality of life, 60-year-old PWH would have a lower life expectancy (QALYs): 17.4 years (14.1 QALYs) and 16.8 years (13.4 QALYs) for male and female individuals, respectively, compared with the general population [male individuals, 21.7 years (18.4 QALYs); female individuals, 24.7 years (20.2 QALYs)]. AAD cumulative incidence was most sensitive to non-HIV-related mortality, engagement in HIV care, and AAD incidence rates.

CONCLUSION

Projected estimates of AAD-associated morbidity, mortality, and quality of life can inform decision-makers and health systems planning as the population of PWH ages. Improved AAD prevention, treatment, and supportive care planning are critical for people aging with HIV.

Age-related experiences of diverse older women living with HIV: A scoping review protocol informed by intersectionality

INTRODUCTION

Older women living with HIV often go unnoticed due to societal biases and stigmas. Despite a rise in cases among older women, there is limited research on the psychosocial factors impacting their experiences. Aging complexities compounded by HIV and menopause affect these women's health, while factors like mental health impact, changing support networks, and ageism with HIV stigma influence their well-being. Existing studies mostly compare older HIV-positive individuals without considering gender and intersectional identities, limiting understanding of their unique experiences. The scarcity of research addressing age-related differences from diverse perspectives delays the development of tailored treatments and interventions.

OBJECTIVES

The study aims to comprehensively explore the age-related experiences of older women with HIV through three sub-questions that address (1) Key experiences, medical and social challenges, and strengths; (2) Impact of intersectional identities on their experiences; and (3) Gaps and limitations in current research.

METHODS

Utilizing a scoping review approach, the study seeks to map existing literature, employing a theoretical framework rooted in Sex- and Gender-Based Analysis Plus (SGBA+). Articles focusing on the age-related experiences of older women living with HIV aged 50 and above will be included. The study selection process will involve two independent reviewers screening articles based on pre-established inclusion criteria. Data extraction and synthesis will follow, analyzing the influence of sex, gender, and other identities on experiences.

DISCUSSION

The study's comprehensive approach aims to bridge gaps in understanding older women's HIV experiences, emphasizing intersectionality. While limited to English-language peer-reviewed articles, this review seeks to offer valuable insights for healthcare, policy, and research, potentially fostering positive change in the lives of diverse older women living with HIV.

HIV-Related Stigma and Multidimensional Frailty Among Older Latinos With HIV

Introduction: Frailty is a geriatric syndrome of increased vulnerability to stressors marked by a higher risk for poor health outcomes. HIV-related stigma is a stressor for Latino people with HIV (PWH) and an important barrier to HIV care. This study examines the association between HIV-related stigma and multidimensional frailty among older Latino PWH. Methods: A cross-sectional design with 120 Latino PWH aged 50 and older was used. Self-reported questionnaires were administered to assess multidimensional frailty (Tilburg Frailty Indicator) and HIV-related stigma (HIV stigma scale). Results: Participants were 59.1 ± 7.0 years old, primarily White-Hispanic (85.00%, n = 102), single (48.33%, n = 58), and male (73.30%, n = 88). Nearly half of the participants were frail (45.85%, n = 55). Compared to non-frail, frail individuals had significantly higher scores in the total HIV-related stigma (M = 98.5 ± 24.7 vs. M = 85.3 ± 25.6, p = .020) and all subscales. The odds of multidimensional frailty were 1.021 times higher for people with higher HIV-related stigma scores (p = .007). This association remained significant after adjustment for income and comorbidities (p = .049). Conclusions: HIV-related stigma among older Latino PWH was significantly associated with their odds of being frail. Efforts to prevent multidimensional frailty should consider addressing HIV-related stigma through age-appropriate and culturally tailored resources for this group.

Human Immunodeficiency Virus in Older Adults

As people with HIV live longer, they can experience increased incidence and earlier onset of chronic conditions and geriatric syndromes. Older people are also at substantially increased risk of delayed diagnosis and treatment for HIV. Increasing provider awareness of this is pivotal in ensuring adequate consideration of HIV testing and earlier screening for chronic conditions. In addition, evaluating patients for common geriatric syndromes such as polypharmacy, frailty, falls, and cognitive impairment should be contextualized based on how they present.

Ageism: the -ism affecting the lives of older people living with HIV

WHO defines ageism as stereotypes, prejudice, and discrimination based on age. Ageism is a multidimensional concept that encompasses multiple components related to the individual, the social group, and the institution in different cultural and environmental settings. In people ageing with HIV these elements include self-stigma, discrimination in society, and experiences in care, many of which are unique to older people. In this Position Paper, we use experience of people with HIV and clinicians taking care of them to explore these issues in high-income countries. The intersectionality of multiple -isms, which affect the lives of older people living with HIV, and ageism enhance several HIV-related issues, including self-inflicted stigma, and loneliness. Research is needed to explore how ageism contributes to worse physical, mental, and social wellbeing outcomes for people with HIV. The model of care for older people living with HIV needs to go beyond virological success by adopting a geriatric mindset, which is attentive to the challenge of ageism and is proactive in promoting a comprehensive approach for the ageing population. All stakeholders and the community should work together to co-create institutional strategies and educational programmes and enable respectful intergenerational dialogue to foster a stigma-free future for older people living with HIV.

Addressing HIV stigma in healthcare, community, and legislative settings in Central and Eastern Europe

INTRODUCTION

Surging HIV prevalence across countries of Central and Eastern Europe (CEE) is largely a result of poor HIV care engagement and a lack of comprehensive support for key populations. This is fostered by widespread stigma across healthcare, community, and legislative settings.

DISCUSSION

Throughout CEE, HIV stigma and intersectional stigma are serious obstacles to providing adequate medical care to people living with HIV. Anticipated and enacted (experienced) stigma from healthcare professionals, and fears of breaches in confidentiality, deter individuals from having an HIV test and engaging in HIV care. Furthermore, negative connotations surrounding HIV infection can lead to discrimination from family, friends, colleagues, and the public, leading to internalized stigma and depression. Key populations that have higher HIV prevalence, such as men who have sex with men, people who inject drugs, transgender individuals, and sex workers, experience additional stigma and discrimination based on their behaviour and identities. This contributes to the concentrated HIV epidemics seen in these populations in many CEE countries. The stigma is exacerbated by punitive legislation that criminalizes HIV transmission and penalizes sexual orientation, drug use, gender identities, and sex work. Despite high levels of HIV stigma and intersectional stigma, there are many evidence-based interventions that have reduced stigma in other parts of the world. Here, we discuss the interventions that are currently being enacted in various countries of CEE, and we suggest additional effective, evidence-based interventions that will tackle stigma and lead to increased HIV care engagement and higher rates of viral suppression. We cover the promotion of the undetectable = untransmittable (U = U) message, stigma-reduction education and training for healthcare professionals, patient-centric approaches for testing and treatment, and advocacy for non-discriminatory legislation, policies, and practices. We also consider targeted stigma-reduction interventions that acknowledge the wider challenges faced by marginalized populations.

CONCLUSIONS

HIV stigma and intersectional stigma in CEE drive poor engagement with HIV testing services and care. Widespread adoption of evidence-based interventions to tackle stigma highlighted in this review will improve the quality of life of people living with HIV, improve HIV care engagement, and ultimately slow the surging HIV prevalence and concentrated epidemics occurring throughout CEE.

Sexual Practices and Predisposition to PrEP Use Among Men Ages 50 Years and Older Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

This study aimed to evaluate the sexual practices of men ages 50 years or older who have sex with men (MSM) and factors influencing their predisposition to use preexposure prophylaxis (PrEP). An analytical cross-sectional study was conducted in Brazil and Portugal with 718 MSM. Of these, 278 (38.7%) were categorized as being at high risk for HIV based on the HIV Incidence Risk Index (HIRI), and 418 (58.2%) expressed a predisposition to use PrEP. Overall, sociodemographic factors and specific sexual practices increased the likelihood of being classified as high risk for HIV, particularly sexual position and sexual activity. However, factors that influenced the predisposition to use PrEP included age group, receptive anal sex, knowledge of postexposure prophylaxis, high HIRI score, and a history of syphilis. These findings underscore the urgent need for health services to provide comprehensive and adequate attention to the realities of this population, considering its complexities and specificities.

Staying hidden: The burden of stigma in PD

BACKGROUND

Despite the myriad motor and non-motor challenges associated with Parkinson's disease (PD) diagnosis, the hidden issue of stigma may be among the most influential factors negatively affecting quality of life. A number of qualitative studies have been published assessing various aspects of stigma in PD, and quantitative studies assert that most people with PD experience stigma during the course of their disease. Stigma is associated with poorer mental and physical health, poorer quality of life, decreased levels of hope, self-esteem and self-efficacy. The resulting stigma can lead to social anxiety and isolation, reluctance to seek medical care, loneliness, depression and anxiety. Therefore, understanding what stigma is, where it comes from, and how it affects people living with PD may offer clinicians and care partners tools to help mitigate the negative effects.

FOCUS

Over the past few decades, we have seen a move away from simply focusing on the effects of a disease (medical model) toward a holistic biopsychosocial approach that considers the role of environmental factors (stigma) when assessing overall well-being. We review some proactive practical suggestions to help people living with PD effectively combat the negative effects of stigma.

CONCLUSION

The additional hidden burden of stigma from PD affects quality of life. Having a better understanding of the role of stigma and its impact may allow clinicians to provide proactive care and greater empathy for those living with the challenges of this disease.

Factors Associated with Antiretroviral Therapy Adherence Among a Community-Based Sample of Sexual Minority Older Adults with HIV

Older sexual minorities (e.g., gay, bisexual) living with HIV are at risk for poor HIV outcomes due to their frequent experience with both psychosocial challenges and structural barriers to care. This study utilized a stochastic search variable selection (SVSS) approach to explore potential psychosocial and structural factors associated with HIV-related health outcomes among a community-based sample of older sexual minorities (N = 150) in South Florida, an U.S. HIV-epidemic epicenter. After SVSS, a forward entry regression approach suggested unstable housing, illicit substance use, current nicotine use, and depression were all associated with poorer ART adherence among older sexual minority adults living with HIV. No associations between potential correlates and biological measures of HIV disease severity were observed. Findings highlight a need to focus on multiple levels of intervention that target a combination of psychosocial and structural factors to improve HIV-care outcomes among older sexual minorities and achieve Ending the HIV Epidemic goals.

HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions

The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.

Non-communicable disease comorbidities in HIV patients: diabetes, hypertension, heart disease, and obstructive sleep apnea as a neglected issue

The present study evaluates the non-communicable disease (NCD) patterns and related risk factors among people living with HIV (PLWH) in Iran. This national cross-sectional survey study was conducted on 1173 confirmed PLWHs with a mean age of 35.35 (56.82 Over 50 years old, 33.90 Under 50 years old) admitted from 15 different provinces in the country. Logistic regression was used to analyze the association of factors with having at least one NCD comorbidity. From 1173 PLWH, 225(19.18%) participants experienced at least one NCD (15.20% and 38.69% among under- and over-50-year-old patients, respectively). The prevalence of heart disease, hypertension, diabetes, and sleep apnea among all patients was 1.59%, 2.05%, 1.55%, and 10.26%, respectively. The similar prevalence for each NCD among those over 50 years was 10.11%, 15.71%, 9.01%, 25.44%, and 1.01%, 1.12%, 1.04%, and 9.23% among those under 50 years, respectively. The odds of being at risk of at least one NCD stood higher in patients over 50 years (ORadj = 2.93, 95% CI 1.96-4.37), married (ORadj = 2.48, 95% CI 1.41-4.35), divorced or widowed (ORadj = 2.78, 95% CI 1.48-5.20), and obese (ORadj = 3.82, 95% CI 2.46-5.91). According to our findings regarding the prevalence of NCDs among patients under 50 years of age, we recommend that policymakers give greater consideration to this group in the screening and care programs for NCDs since adults and the elderly are both vulnerable to the risk factors for developing NCDs.

Qualitative Analysis of Multiple Sources and Dimensions of Stigma Among Older Adults Living With HIV Infection Released From Corrections

While sources of stigma associated with HIV, incarceration, and aging have been explored separately, the concurrent effects of these multiple sources have been understudied. We conducted in-depth interviews with 48 older adults over 50 years of age with HIV infection who were returning from correctional settings concerning their experiences of stigma. Participants described HIV-related stigma substantially more often than incarceration-related stigma and a greater number of stigma experiences as time passed from release. Anticipated stigma experiences were frequently associated with HIV. Enacted stigma was often related to incarceration. Internalized stigma was associated with both HIV and incarceration. However, participants often described aging as a positive experience of gaining wisdom and control over their life. The findings indicated that multiple sources of stigma affect different dimensions of stigma. Postrelease interventions may benefit from addressing increasing experiences of stigma in the rapidly growing population of older adults living with HIV with a history of incarceration.

Identifying the needs of older people living with HIV (≥ 50 years old) from multiple centres over the world: a descriptive analysis

BACKGROUND

Older People Living with HIV (OPWH) combine both aging and HIV-infection features, resulting in ageism, stigma, social isolation, and low quality of life. This context brings up new challenges for healthcare professionals, who now must aid patients with a significant comorbidity burden and polypharmacy treatments. OPWH opinion on their health management is hardly ever considered as a variable to study, though it would help to understand their needs on dissimilar settings.

METHODS

We performed a cross-sectional, comparative study including patients living with HIV aged ≥50 years old from multiple centers worldwide and gave them a survey addressing their perception on overall health issues, psychological problems, social activities, geriatric conditions, and opinions on healthcare. Data was analyzed through Chisquared tests sorting by geographical regions, age groups, or both.

RESULTS

We organized 680 participants data by location (Center and South America [CSA], Western Europe [WE], Africa, Eastern Europe and Israel [EEI]) and by age groups (50- 55, 56-65, 66-75, >75). In EEI, HIV serostatus socializing and reaching undetectable viral load were the main problems. CSA participants are the least satisfied regarding their healthcare, and a great part of them are not retired. Africans show the best health perception, have financial problems, and fancy their HIV doctors. WE is the most developed region studied and their participants report the best scores. Moreover, older age groups tend to live alone, have a lower perception of psychological problems, and reduced social life.

CONCLUSIONS

Patients' opinions outline region- and age-specific unmet needs. In EEI, socializing HIV and reaching undetectable viral load were the main concerns. CSA low satisfaction outcomes might reflect high expectations or profound inequities in the region. African participants results mirror a system where general health is hard to achieve, but HIV clinics are much more appealing to them. WE is the most satisfied region about their healthcare. In this context, age-specific information, education and counseling programs (i.e. Patient Reported Outcomes, Patient Centered Care, multidisciplinary teams) are needed to promote physical and mental health among older adults living with HIV/AIDS. This is crucial for improving health-related quality of life and patient's satisfaction.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

COVID-19-related stigma and its relationship with mental wellbeing: A cross-sectional analysis of a cohort study in Japan

Objective

Social stigma related to coronavirus disease (COVID-19), i. e., COVID-19 stigma, forms a burden on people socially, economically, and mentally. This study assessed COVID-19 stigma using a scale to identify a population likely to exhibit higher prejudice against COVID-19 itself as well as those infected with COVID-19.

Methods

We adapted and modified the Cancer Stigma Scale to assess COVID-19 stigma and used it as the baseline survey of a cohort study in Japan. The questionnaire was disseminated to 1,573 participants (51.7% men) between December 2020 and March 2021. The questionnaire items included the infection status of individuals close to the respondent and their preventive behaviors related to COVID-19, quality of life (QOL; using the EuroQoL 5-Dimension 5-Level [EQ-5D-5L]), and psychological distress (using the 6-item Kessler Psychological Distress Scale [K6]). Exploratory and confirmatory factor analyses were performed to validate the COVID-19 stigma scale, and we further used the structural equation modeling (SEM) to assess the relationship with QOL and psychological distress.

Results

COVID-19 stigma was calculated for the 257 (16.3%) participants who responded to the questionnaire. The mean age (standard deviation) was 54.5 (14.4) years, and 50.2% were men. Factor analysis revealed a five-factor model: Awkwardness (feeling uncomfortable being with a person infected before), Severity (fear of not being able to return to normal after infection), Avoidance (attitude of avoiding infected persons), Policy Opposition (expecting more public funding investment), and Personal Responsibility (believing that infected persons themselves are responsible for their infection). Participants > 70 years had the highest scores among other age groups considering all factors except for Policy Opposition. Standardized coefficients in SEM for COVID-19 stigma (latent variable) was highest for Severity (beta = 0.86). Regression coefficients of COVID-19 stigma on K6 and QOL were 0.21 (95% confidence interval [CI] 0.074-0.342) and -0.159 (95% CI -0.295-0.022), respectively.

Conclusion

People aged ≥ 70 years are more likely to exhibit COVID-19 stigma. Additionally, the results indicate that COVID-19 stigma impacts QOL and psychological distress.