HIV/AIDS in older women: unique challenges, unmet needs

Increases in the susceptibility of human endometrial CD4+ T cells to HIV-1 infection post-menopause are not dependent on greater viral receptor expression frequency

Epidemiological evidence suggests that post-menopausal women are more susceptible to HIV infection following sexual intercourse than are younger cohorts for reasons that remain unclear. Here, we evaluated how menopause-associated changes in CD4+ T cell numbers and subsets as well as HIV coreceptor expression, particularly CCR5, in the endometrium (EM), endocervix (CX), and ectocervix (ECX) may alter HIV infection susceptibility. Using a tissue-specific mixed cell infection model, we demonstrate that while no changes in CD14+ macrophage infection susceptibility were observed, CD4+ T cell HIV-1 infection frequency increases following menopause in the EM, but not CX nor ECX. Unexpectedly, the CD4+ T cell expression of two known correlates of HIV infection susceptibly, CCR5 and integrin-α4β7, increased following menopause across all three tissues despite only being associated with increased infection frequency in EM derived CD4+ T cells. After controlling for changes in the expression of either receptor, both CCR5 and α4β7 expressing CD4+ T cells isolated from the EM of post-menopausal women remained more susceptible to HIV-1 infection than those isolated from pre-menopausal women. Shifts in T helper subset composition, including increases in Th1 frequency and decreases in Th17 and Treg frequency were also observed in the EM only following menopause, but did not correlate with increased infection frequency. Treatment of EM derived CD4+ T cells with 17β-estradiol (E2) prior to viral infection, reduced infection frequency independent of changes in either CCR5 or α4β7 expression frequency. Our results demonstrate that the susceptibility of EM derived CD4+ T cells to HIV-1 infection increases post menopause but is unlikely to be driven by increased expression frequency of either CCR5 or integrin-α4β7. These findings contribute to our understanding of how advanced age alters HIV infection risk which will become increasingly important as the human population continues to age.

"It's like it's the old boys club"-the age-related experiences of diverse older women living with HIV: A scoping review and consultative exercise

OBJECTIVES

HIV is often under-recognized in older individuals, particularly women, despite a significant number of new cases being diagnosed in those aged >50 years. This review aimed to understand the age-related experiences and challenges faced by women aged ≥50 years living with HIV through an intersectional perspective.

METHODS

We conducted a systematic scoping review using the framework by Arksey and O'Malley, refined by Levac, Colquhoun, and Peters, and informed by a Sex- and Gender-Based Analysis Plus (SGBA+) approach. The research questions were developed in consultation with community advisory stakeholders. A comprehensive search strategy was used, targeting categories related to 'aged,' 'HIV,' and 'women' based on scoping review and Peer Review of Electronic Search Strategies guidelines. We included peer-reviewed studies where at least 50% of participants were women aged ≥50 years and living with HIV, focusing on their age-related experiences in health or social contexts. Two independent reviewers applied inclusion criteria through a two-level screening process. Data extraction included details on publication type, study characteristics, participant recruitment, and results. Findings were synthesized and presented to a stakeholder advisory committee for additional insights. Stakeholder input from an advisory committee was incorporated into the findings, providing additional context and enhancing the interpretation of the results.

RESULTS

The review included 21 articles. Key findings revealed the intersectional challenges faced by women aged ≥50 years living with HIV, such as stigma, emotional resilience, social support networks, and health management strategies. These findings highlight the complex interplay of factors influencing their lives, from concerns about sharing HIV status to strategies for managing health. The review also identified research gaps and underscored the need for comprehensive studies on the intersectional dynamics affecting health outcomes in this population.

CONCLUSIONS

This review underscores the complex challenges and strengths of women aged ≥50 years living with HIV, emphasizing the need for tailored interventions and support services that recognize their intersecting identities and unique needs. Addressing these issues is essential for ensuring equitable access to care and fostering resilience within this community.

Sex differences in COVID-19 vaccine confidence in people living with HIV in Canada

Background

Understanding the roots of vaccine confidence in vulnerable populations, such as persons living with HIV (PLWH), is important to facilitate vaccine uptake, thus mitigating infection and spread of vaccine-preventable infectious diseases. In an online survey of PLWH conducted in Canada during winter 2022 (AIDS and Behav 2023), we reported that the overall COVID-19 vaccination uptake rate in PLWH was similar by sex. Here, we examined attitudes and beliefs towards vaccination against COVID-19 based on sex.

Methods

Between February and May 2022, PLWH across Canada were recruited via social media and community-based organizations to complete an online survey consisting of a modified Vaccine Hesitancy Scale (VHS) questionnaire with items from the National Advisory Committee on Immunization Acceptability Matrix. Descriptive statistics were used to summarize participant characteristics and responses to the VHS questionnaire by sex. The effect of biological sex on total VHS score, two subscales ("lack of confidence" and "perceived risk") was assessed separately by linear regression adjusting for other key baseline variables.

Results

Of 259 PLWH, 69 (27 %) were females and 189 (73 %) were males. Sixty-six (26 %) of participants self-identified as a woman, 163(63 %) as a man and 28(11 %) as trans/two-spirited/queer/non-binary/agender/other. The mean age (SD) was 47 ± 14 years. Females were less likely to believe that COVID-19 vaccination was: important for his/her own health (71 % vs. 86 %); a good way to protect themselves from infection (68 % vs. 86 %); that getting the COVID-19 vaccine was important for the health of others in his/her community (78 % vs. 91 %); believed recommendations by their doctor/health care provider about COVID-19 vaccines (78 % vs. 88 %); that information about COVID-19 vaccines from public health officials was reliable and trustworthy (56 % vs. 75 % vs); COVID-19 vaccines are effective in preventing COVID-19 infections (61 % vs. 82 %) and that all COVID-19 vaccines offered by government programs in their communities were important for good health (70 % vs. 87 %). Although more males than females felt that new vaccines generally carry more risks than older vaccines (19 % vs 16 %,), fewer males than females endorsed concern about serious side effects of COVID-19 vaccines (33 % vs 45 %).The linear regression model showed females had a significantly higher VHS total score than males (adjusted mean difference 0.38; 95 % confidence interval (CI) 0.13-0.64; p = 0.004), indicating greater COVID-19 vaccine hesitancy among females. It was observed that females had a greater "lack of confidence in vaccines" score than males (adjusted mean difference 0.43; 95 % CI 0.14-0.73; p = 0.004). We did not observe a significant difference in "perceived risk in vaccines" between males and females (adjusted mean difference 0.20; 95 % CI -0.07-0.46; p = 0.1). The inadequate number of participants self-identifying as different from biological sex at birth prevented us from analyzing the VHS score based on gender identity.

Conclusions

Among PLWH, females showed greater COVID-19 vaccine hesitancy than males. Specifically, compared with males, females had a higher level of lack of confidence in vaccines. Fewer females than males believed that COVID-19 vaccines had health benefits at both the personal and societal levels and that recommendations made by their doctor/health care provider and public health officials are reliable and trustworthy. Further investigation into reasons for this difference in opinion still needs to be elucidated. Educational interventions targeted toward females living with HIV are especially needed to increase confidence in vaccination.

Temporal and spatial convergence: the major depressive disorder burden attributed to intimate partner violence against women

Background: There is a strong causal relationship between intimate partner violence and major depressive disorder, which partly endangers women's safety across the life course and potentially affects the development of future generations. The international community has placed a high priority on addressing the intimate partner violence and the resulting burden of mental illness. Data collection needs to be captured across the temporal trend and spatial distribution for major depressive disorder attributed to intimate partner violence, to reflect the priorities and expectations of survivors.Method: This research obtained raw disability-adjusted life years (DALYs) information for major depressive disorder attributed to intimate partner violence from the Global Burden of Disease 2019. Using estimated annual percentage change and two-way fixed effects models, a secondary spatio-temporal analysis of the age-standardized DALYs rate from 1990 to 2019 was performed.Results: In 2019, DALYs lost among women experiencing major depressive disorder (3.16 million) accounted for 37.18% of the DALYs lost worldwide due to intimate partner violence. The age-standardized DALYs rate of major depressive disorder attributed to intimate partner violence was 108.57 per 100,000. The highest was concentrated in the menopausal transition (45-55), with 133.61 per 100,000, and particularly distributed in Uganda (429.31 per 100,000). The early reproductive period (15-19) showed the increasing age-standardized DALYs rate from 1990 to 2019, which was mainly driven by Malaysia (3.73% per year). Furthermore, countries with higher initial levels of the age-standardized DALYs rate were growing faster than those with lower levels.Conclusions: The burden of major depressive disorder attributed to intimate partner violence showed biological and spatial inequality, prioritized intervention should be targeted at vulnerable stage women in their early reproductive period and menopausal transition. Combined political, socio-cultural as well as medical measures to prevent violence and treat major depressive disorder should be implemented and developed.

'If I don't take care of me, then I can't be there for others:' a qualitative study of caregiving relationships among older women living with HIV

OBJECTIVE

The population of women ages 50 years and older living with HIV is increasing. Yet, little is known about the care networks that older women living with HIV (OWLH) use to manage their health. The goal of this study was to explore the caregiving and care receiving relationships among OWLH and how these relationships impact HIV management.

METHODS

OWLH aged 50 years and older were recruited from clinics and community-based organizations across the U.S. We conducted semi-structured, in-depth phone interviews and performed content and thematic analysis on transcripts.

RESULTS

Participants (N = 23) were on average 60 years old and had been living with HIV for an average of 23.7 years. Participants 1) relied on diverse care networks; 2) were caregivers for grandchildren and parents; 3) had pride and joy in being caregivers; and 4) were highly proactive in their own HIV management. Care networks promoted self-love and acceptance. However, concerns about aging with HIV were still highly prevalent.

CONCLUSION

Being a caregiver and care recipient are sources of meaning and strength to help OWLH manage HIV. Public health programs should consider engaging both OWLH and their care networks in healthcare discussions and educational efforts.

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.

A scoping review: Forced/coerced sterilization as a socio-cultural risk factor for sexually transmitted HIV for older Black women

Understanding socio-cultural factors that influence older (age 50 and up) Black women's risk for sexually transmitted HIV has often been absent from policies and programs. This scoping review asked: What does academic literature reveal about forced/coerced sterilization as a risk factor for older Black women who are disproportionately affected by sexually transmitted HIV? Using the Arksey and O'Malley scoping review methodology, the authors identified academic and gray literature published between 2000 and 2023. Of the 407 sources identified and screened, three articles met the criteria for inclusion. One study focused on birth control conspiracy beliefs, another focused on racial differences in Norplant use, and the third focused on the intergenerational transmission of mistrust of medical care that influences HIV prevention among Black Americans. The study findings suggest that because the link has not been made between socio-cultural factors that impact older Black women's reproductive health practices, further investigation is warranted.

Gender-based stigma and the prevention and treatment of HIV/AIDS among older women: A scoping review protocol

INTRODUCTION

The population of women aged 50 years and older living with HIV is increasing. Older women face unique challenges in the prevention and management of HIV; however, they are often under engaged in HIV/AIDS research. One such challenge is gender-based stigma, which can be manifested through harmful gendered stereotypes, discrimination, prejudice, and sexism that could potentially hinder HIV care engagement among this population. We propose a scoping review to identify and synthesize evidence pertaining to how experiences of gender-based stigma impacts HIV prevention and care among older women.

MATERIALS AND METHODS

We will use the framework by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) to conduct this scoping review. We will search MEDLINE/PubMed, Web of Science, PsycINFO, CINAHL and Scopus for empirical literature published between January 1981 and the date of search commencement. Supplementary screening will be conducted using backwards citation chaining of the final list of included full-text articles. Two reviewers will independently screen all titles and abstracts for articles that meet the predetermined inclusion criteria. Two reviewers will also screen full-text articles and chart data using a standardized data collection form.

RESULTS

We will synthesize the findings through tables, charts, and narrative summaries. We will also identify gaps in the current literature and provide recommendations for future research. Findings will be shared at conferences and submitted to a peer-reviewed publication.

DISCUSSION

To our knowledge, this will be the first scoping review to examine gender-based stigma in relation to HIV prevention and care among older women. We anticipate that our results will be of interest to older women living with HIV, healthcare providers, policy makers, and community activists working to improve quality of life and care experiences for older women living with HIV.

Intersectionality Can Shape the Support Networks of Older Women with HIV

Older women living with HIV are an especially vulnerable population due to their experience of multiple stigmas resulting from intersectional identities. Using an intersectional convoy model to conceptualize social relations, we consider how HIV-related stigma, age, gender, race/ethnicity, and socioeconomic position shape access to support resources through personal networks. We briefly review existing research on how intersecting identities and structural inequities might influence the structure, composition, and function of support networks among older people with HIV. Potential applications of the intersectional convoy model and implications for research and practice are discussed.

How is Aging Perceived to Affect Well-being in Women Older than 50 Years Living With HIV? A Qualitative Systematic Review

ABSTRACT

Advances in HIV treatment have led to more people with HIV living to 50 years and older. No reviews have qualitatively analyzed and synthesized the literature relevant to theory and practice for well-being specifically in Women living with HIV (WLWH) aged 50 years and older. Sixteen eligible qualitative studies were critically appraised and thematically synthesized to investigate how aging was perceived to affect well-being in WLWH aged 50 years and older. Six themes demonstrated how HIV-related stigmas negatively affected social well-being, and how adjusting to living and aging with HIV negatively affected psychological and physical well-being of older WLWH. Holding caring roles also negatively affected physical well-being of WLWH. Globally, majority women aging with HIV were found to experience additional stigmas. Further research could elucidate how HIV-related stigma affects the well-being of global majority women living and aging with HIV. Recommendations are made for future HIV-related clinical practice and theory development.

Adapting, testing, and refining a resilience intervention for older women with HIV: An open pilot study

Half of persons with HIV in the United States (US), many of whom are women, are over age 50. Aging women with HIV (WWH) face unique biopsychosocial challenges, including stigma, the physiological effects of aging, and illness-associated stressors. Resilience interventions can build awareness of such stressors and aid in facilitating the relaxation response; however, no existing interventions specifically cater to the needs of older WWH. The content of the Relaxation Response Resiliency Program, which teaches positive psychology strategies, relaxation techniques, and cognitive behavioral skills, was adapted for older WWH. Thirteen WWH over 50 participated in an open pilot of the adapted intervention to iteratively refine the program and its procedures. Participants attended either 8 or 10 weekly group sessions; three groups were conducted in total. Pre- and post-intervention assessments and qualitative exit interviews were conducted. Among completers, an increase in resilience was observed. Though significance testing was not conducted, social support also increased, and depression, anxiety, and HIV stigma decreased from pre- to post-intervention. Over half of eligible women enrolled; completers reported high satisfaction with the program. However, retention was difficult; six participants withdrew or were lost to follow-up. Mean number of sessions attended was 3.5 in the 8-session group and 5 in the 10-session groups. In this small sample, the adapted intervention led to a clinically meaningful increase in resilience, though recruitment and retention were challenging. Further refinements to the intervention are needed to minimize attrition and increase acceptability before additional testing is initiated.

Depression and HIV risks: Engaging older African American women in HIV prevention education through the church

This report describes the recruitment of a sample of older African American women to test the effectiveness of an educational HIV prevention intervention that sought to reduce depressive symptoms and thereby HIV risks in this population. The outreach venue is the Black church. A framework for maximizing response is suggested. Of 62 women who participated in two arms of the intervention, 29 were assigned randomly to a four-session discussion group (experimental condition) and 33 were assigned to a one-session informational group (control condition) focused on HIV prevention education. Between-within subjects analyses of variance showed that participation in the study was associated with a significant improvement in the women's psychological status, i.e., decreased depressive symptoms. This change in depressive symptoms was due in part to the experimental condition assignment. Implications for future HIV prevention interventions, research, and methods used to maximize the probability of response among older African American women are discussed.

Prevalence of Physical Health, Mental Health, and Disability Comorbidities among Women Living with HIV in Canada

Life expectancy for people living with HIV has increased, but management of HIV is now more complex due to comorbidities. This study aimed to measure the prevalence of comorbidities among women living with HIV in Canada. We conducted a cross-sectional analysis using data from the 18-months survey (2014−2016) of the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS). Self-report of diagnosed conditions was used to measure lifetime prevalence of chronic physical conditions, current mental health conditions, and disabilities. We examined frequency of overlapping conditions and prevalence stratified by gender identity, ethnicity, and age. Among 1039 participants, 70.1% reported a physical health diagnosis, 57.4% reported a current mental health diagnosis, 19.9% reported a disability, and 47.1% reported both physical and mental health comorbidities. The most prevalent comorbidities were depression (32.3%), anxiety (29.5%), obesity (26.7%, defined as body mass index >30 kg/m2), asthma/chronic obstructive pulmonary disease (23.3%), sleep disorder (22.0%), drug addiction (21.9%), and arthritis/osteoarthritis (20.9%). These results highlight the complexity of HIV care and the important prevalence of comorbidities. Personalized health care that integrates care and prevention of all comorbidities with HIV, with attention to social determinants of health, is necessary to optimize health and well-being of women living with HIV.

How do geriatricians feel about managing older people living with HIV? A scoping review

PURPOSE

The proportion of people living with HIV being older adults is increasing and due to high rates of multimorbidity and frailty within this group geriatricians are well placed to contribute to their care. However, little is known about how geriatricians feel about this new opportunity.

METHODS

A scoping review was performed following the Arksey & O'Malley's methodological framework with nine databases searched in December 2021 for studies reporting the experiences or views of geriatricians on caring for people living with HIV. Study inclusion was not limited by language or year of publication. Narrative reviews were excluded. Two reviewers independently performed the extraction using predetermined criteria. A descriptive analysis of extracted information was performed.

RESULTS

Six publications reporting four studies, all conducted in the USA, were identified. The current barriers to geriatricians being involved in the care of older people living with HIV are: their current experience in managing people living with HIV, their knowledge of HIV, specific issues related to older people living with HIV and screening for HIV in older people as well as their attitudes to people living with HIV and experience of managing older LGBTQ + people.

CONCLUSION

Prior to geriatricians being routinely involved in the care of older people living with HIV further research outside of the USA is required. Geriatricians will also require specific training which should be incorporated into geriatric medicine training curricula as well as the creation of learning tools and quality clinical practice guidelines ideally created in collaboration with HIV organisations.

Exploring the Psychosocial Impact of Living With HIV on Minority Older Women

BACKGROUND: Among older adults, minority older women will account for 60% of the new HIV diagnoses. The psychosocial impact of living with HIV among this vulnerable population narrated by their own voices has been understudied. AIMS: The purpose of this study was to explore the psychosocial impact of living with HIV on minority older women. METHODS: In-depth interviews were conducted with 28 minority older women living with HIV at an Ambulatory Care Center HIV Clinic in South Florida. All interviews were audio-recorded and transcribed verbatim. Conventional content analysis was used to identify and define the major themes that emerged from the interviews. Questions included those concerning description of life after the HIV diagnosis, most challenging aspects of life after the diagnosis, and daily activities since the diagnosis. RESULTS: The analysis of the interview data led to five main themes: (I) Social Impact of HIV, (II) Threats to Health and Well-Being, (III) HIV as a Death Sentence, (IV) Spirituality, and (V) HIV Treatment Adherence. In their narratives, women described a myriad of psychosocial issues such as depressed mood, isolation, economic challenges, stigma, anhedonia of interest, fear of death, among others. CONCLUSIONS: There is a compelling empirical need for rapid implementation of a culturally tailored, holistic, low-cost, multistrategy intervention to early screen and reduce the psychosocial impact of HIV among minority older women.

Using Focus Group Feedback to Identify Patient-Centered Initiatives for Older Persons with HIV

Objectives: This study assessed how few community-based programs target older people living with HIV.Methods: We conducted four focus groups comprised of people 50 and older with HIV (N = 32; gay/bisexual men, heterosexual men, women, and Spanish-speakers) to inform HIV program development by exploring the services in which participants were actively involved, along with the services they wanted to receive.Results: Using inductive thematic qualitative analysis, four themes were identified pertaining to program development: (a) types of currently utilized HIV service organizations; (b) dissatisfaction with HIV programming and services; (c) participants' preferred programming, courses, groups, or activities; and (d) desire to serve as peer mentors.Conclusions: Results highlight the need for community-based organizations to address social engagement and isolation among older people living with HIV.Clinical implications: These findings exemplify the need for programs to be specifically designed for OPH, and created with the primary goals of socialization and helping develop social support networks.

A Qualitative Study on the Social Determinants of HIV Treatment Engagement Among Black Older Women Living With HIV in the Southeastern United States

ABSTRACT

Black older women living with HIV (BOWLH) in the United States are disproportionately affected by HIV infection and poor treatment engagement rates, often caused by multiple social determinants of health. In this descriptive qualitative study, we interviewed 17 BOWLH to investigate the facilitators and barriers to HIV treatment engagement. Data were analyzed using the socioecological framework. Findings demonstrate the positive influences of supportive social networks, perceived benefits, HIV-related knowledge, raising HIV awareness in communities, and impact of HIV state laws. The highlighted barriers were mainly low income, substance use, HIV-related stigma, influence of stereotypes and assumptions about older women living with HIV, and health insurance. Religion, managing comorbidities, attitude toward, HIV disclosure, and caregiving roles had both positive and negative influences on engagement. These findings illuminate factors of HIV treatment engagement that might be culturally founded; disseminating these factors to health care professionals is a critical intervention to support this population.

‘It feels like my visibility matters’: Women ageing with HIV overcoming the ‘violence of invisibility’ through community, advocacy and the radical act of care for others

Objectives:

A participatory qualitative study exploring women’s experiences of ageing with HIV in London, United Kingdom. The research considered how the concept of ‘community’ was relevant to women’s experiences and what constructions of ‘community’ could be discerned in the experiences, accounts given and discourses employed by older women living with HIV.

Methods:

The research presented in this article was conducted as a PhD study between 2015 and 2019. The study was structured in multiple and overlapping phases, and adopted a feminist and participatory approach. The methods used in the research were as follows: participatory literature review, participatory creative workshops, policy review and stakeholder interviews, life story interviews, and a participatory analysis workshop.

Results:

Eighteen women living with HIV aged over 50 participated in creative workshops and fourteen women in life story interviews. Women’s experiences of ageing with HIV are shaped by intersecting identities, community responses, and personal connections. Ageing with HIV brings challenges, added to and augmented by other difficulties women face in their lives, but women draw on individual and community assets in order to adapt, cope and thrive. Belonging to a community of women living with HIV and a broader community of people living with HIV created a vital space of safety, in which women found support, advice, and meaning.

Conclusions:

Women ageing with HIV countered the ‘violence of invisibility’ through forming community with other women living with HIV, rejecting stigma, and enacting a personal form of advocacy through care for others.

Exploring Intimate Partner Relationships before and after HIV Diagnosis among Minority Older Women

OBJECTIVES

Literature shows that sexual activity remains important at older age and is a valued part of life. However, little is known about the intimate partner relationships (IPR) among minority older women living with Human Immunodeficiency Virus (HIV). The purpose of this study is to explore the effect HIV diagnosis had on the intimate partner relationships (IPR) among minority older women living with HIV (MOWH).

METHODS

Qualitative descriptive study. A total of 28 MOWH (Black and Latinas) aged 50 years and older participated in face to face semi-structured in-depth interviews. Interviews were analyzed using content analysis.

RESULTS

Three themes emerged from the analysis: (a)"Intimate partner relationships before HIV diagnosis" that revealed sexual practices increasing the risk for HIV in their intimate relationships; (b)"Facing relationship consequences of HIV disclosure after diagnosis" explored the consequences of HIV disclosure, and how disclosure determined the future of their intimate relationships; and (c) "Intimate partner relationships after HIV diagnosis" described the quality of intimate partner relationships and changes after HIV diagnosis.

CONCLUSIONS

Results from this study contribute to understanding and increasing awareness of the effect of HIV on the intimacy of MOWH.

CLINICAL IMPLICATIONS

Education provided by health care workers and interventions targeting MOWH should address the effect of HIV in IPR, address MOWH's concerns about it, and help them to improve their overall health.

A Web-Based HIV/STD Prevention Intervention for Divorced or Separated Older Women

BACKGROUND AND OBJECTIVE

Sexually transmitted diseases (STDs) are increasing among older adults concomitant with a rise in divorce after the age of 50 years. The objective of this study was to examine the effectiveness of a web-based human immunodeficiency virus (HIV)/STD risk reduction intervention for divorced and separated women aged more than 50 years.

RESEARCH DESIGN AND METHODS

Two hundred nineteen divorced or separated women, aged 50 years and older, participated in 60-day randomized pre-post control group study. Recruitment occurred via health agencies in Boston and Columbia, SC, and Craigslist advertisements placed in Boston, Columbia, Charleston, New York City, Washington DC, Baltimore, Chicago, Atlanta, Orlando, and Miami.

RESULTS

Intervention group reported greater intention to practice safe sex compared to the control group (B = .55, p = .03). Intention to practice safe sex differed by perceived stress (B = .15, p = .005), with no difference between control and intervention groups for those with low levels of stress. For high levels of stress, intervention group reported greater intention to practice safe sex compared to controls. Sexual risk was reduced by 6.10 points (SD: 1.10), and self-efficacy for sexual discussion was increased by 2.65 points (SD: 0.56) in the intervention group.

DISCUSSION AND IMPLICATIONS

A web-based intervention represents a promising tool to reduce HIV/STD risk among older women. Offering HIV/STD education in the context of other topics of interest to at-risk older women, such as divorce, may solve the problem of at-risk older women not seeking out prevention information due to lack of awareness of their heightened risk.

HIV Pathogenesis in the Human Female Reproductive Tract

PURPOSE OF REVIEW

Women remain disproportionately affected by the HIV/AIDS pandemic. The primary mechanism for HIV acquisition in women is sexual transmission, yet the immunobiological factors that contribute to HIV susceptibility remain poorly characterized. Here, we review current knowledge on HIV pathogenesis in women, focusing on infection and immune responses in the female reproductive tract (FRT).

RECENT FINDINGS

We describe recent findings on innate immune protection and HIV target cell distribution in the FRT. We also review multiple factors that modify susceptibility to infection, including sex hormones, microbiome, trauma, and how HIV risk changes during women's life cycle. Finally, we review current strategies for HIV prevention and identify barriers for research in HIV infection and pathogenesis in women. A complex network of interrelated biological and sociocultural factors contributes to HIV risk in women and impairs prevention and cure strategies. Understanding how HIV establishes infection in the FRT can provide clues to develop novel interventions to prevent HIV acquisition in women.

Developing a pilot lifestyle intervention to prevent cardiovascular disease in midlife women with HIV

BACKGROUND

Background: Women with HIV (WWH) are at elevated risk for cardiovascular disease (CVD) compared to men with HIV. Lifestyle interventions, like the Diabetes Prevention Program (DPP), may reduce CVD risk, but most fail to address barriers to healthy behaviors facing WWH.

OBJECTIVE

Objective: To inform the adaptation of the DPP for midlife WWH, pilot the modified intervention, and assess feasibility, acceptability, and implementation barriers.

METHODS

Methods: Interviews were conducted with cisgender, English-speaking WWH ages 40-59 to assess intervention preferences. The adapted DPP was piloted and evaluated. CVD knowledge, CVD risk perception, quality of life, and physical activity were assessed pre- and post-intervention.

RESULTS

Results: Eighteen WWH completed interviews. Adaptations included reducing the number of sessions and adding HIV, CVD, stress, aging, menopause, and smoking content. Of 14 women contacted for the pilot, seven completed a baseline, five attended group sessions, and five completed a post-treatment assessment. Attendance barriers included transportation access and costs. Satisfaction was moderate; informal exit interviews indicated that women would recommend the program. CVD knowledge, perceived risk, and physical activity increased, and fatigue and mental health improved. Content on nutrition, aging, HIV, and stress was seen as most useful; suggested changes included group exercises and additional content on recipes, HIV management, and aging.

CONCLUSIONS

Conclusions: Midlife WWH reported benefits from our adapted intervention. Increases in CVD knowledge and perceived CVD risk suggest improved awareness of the impact of lifestyle behaviors. Retention was adequate; socioeconomic barriers were common. Intervention feasibility and acceptability may be improved via remote access and further content customization.

Emergence of Drug Resistance in the Swiss HIV Cohort Study Under Potent Antiretroviral Therapy Is Observed in Socially Disadvantaged Patients

BACKGROUND

The rate of acquired human immunodeficiency virus type 1 (HIV-1) drug resistance (ADR) has fallen dramatically since introduction of combined antiretroviral therapy (cART) in Switzerland. However, clinical experience indicates that there are still patients at risk of newly acquiring drug resistance despite having access to cART. Here, we characterized risk factors for ADR, to improve patient care and prevent emergence of drug resistance and treatment failure.

METHODS

We performed a case-control study to identify risk factors for ADR in all patients starting their first cART in the Swiss HIV Cohort Study (SHCS) since 1996. The SHCS is highly representative and includes >75% of patients receiving ART in Switzerland. To this end, we implemented a systematic medical chart review to obtain more detailed information on additional parameters, which are not routinely collected in the SHCS. The collected data were analyzed using univariable and multivariable conditional logistic regression.

RESULTS

We included in our study 115 cases and 115 matched controls. Unemployment (multivariable odds ratio [mOR], 2.9 [95% confidence interval {CI}, 1.3-6.4]; P = .008), African origin (mOR, 3.0 [95% CI, 1.0-9.2]; P = .047), comedication with anti-infectives (mOR, 3.7 [95% CI, 1.0-12.6]; P = .045), and symptoms of mental illness (mOR, 2.6 [95% CI, 1.2-5.5]; P = .012) were associated with ADR in the multivariable model.

CONCLUSIONS

Although ADR has become very rare with cART due to new potent therapies, patients in socially challenging life situations or presenting with mental health issues are at higher risk for drug resistance. Prompt identification and adequate support of these patients before ADR will prevent treatment failure and HIV-1 transmission.

‘I've never given it a thought’: older men's experiences with and perceptions of ageism during interactions with physicians

The subjective experience of ageism among older men has received little research attention. This study examines older Canadian men's experiences with and perceptions of ageism during interactions with physicians. In-depth, face-to-face interviews were conducted with 21 men aged 55 years and over. The findings indicate a seeming lack of awareness of ageism among many, and many did not believe ageism was likely to occur during patient–physician interaction. Negative stereotyping of older patients was common. A large majority of the participants reported that they had not personally experienced ageism during a medical encounter, nor were they concerned about it. Numerous rationales were proffered as explanations of why a particular participant had not experienced ageism and who was more likely to be a target.

Factors Associated with Lower HIV Testing Rates in an Insured Urban Population

BACKGROUND

As of 2017 the Centers for Disease Control and Prevention (CDC) estimated that there were over one million individuals living with HIV/AIDS in the United States (CDC, 2017). Regionally the epicenter of HIV infection is in Washington DC with a prevalence rate of 1.9% (HAHSTA, 2018). Several wards including 5, 6, 7 and 8 are disproportionately impacted. Although the lack of insurance has been identified as a challenge for HIV detection and linkage to care, many insured individuals deny previous HIV testing. We implemented a routine HIV screening program in our institution since 2006. We present an analysis of our HIV testing data over a 42-month period to assess factors leading to lower HIV testing rates in an urban insured population.

METHODS

Rapid HIV screening was conducted using an opt-out methodology in the emergency department (ED) and an outpatient testing site (OTS) at Howard University Hospital (HUH). Data analysis was performed for clients aged 30-80 years.

RESULTS

Of the 20,008 adults tested the majority (92.4%) were African Americans (AA), and 52% were men. Overall 88 % had health insurance, most (74%) were covered by Medicaid. Out of those insured 9% (1637) reported no previous HIV testing. In this group (64%) were 50 years and older. Unprotected sex was the leading reported risk factor (19%).

CONCLUSION

1637 of those insured reported no previous HIV testing. Age greater than 50 and unprotected sex were significant risk factors. Health insurance status did not always correlate with previous testing. HIV prevention efforts should target this population with appropriate messaging and screening during routine evaluations.

Prevalence and Correlates of Self-Rated Successful Aging Among Older Women Living With HIV

Despite marked gains in longevity attributable to antiretroviral therapy (ART), older women living with HIV (OWLH) experience substantial health challenges, and few studies addressed whether they can achieve successful aging (SA). This is among the first studies examining prevalence and psychosocial correlates of self-rated SA (SRSA) among OWLH and women at risk of HIV.

Quality of life of older women living with HIV: comparative assessment of physical and mental health-related markers using a large Canadian Sexual and Reproductive Health Cohort Study

Objective: This study assessed and compared physical and mental health components of quality of life (QoL) for older and younger women living with HIV (WLWH). Method: Using survey data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study, demographic, well-being, and physical and mental health-related QoL (HR-QoL) variables were compared between older (≥50 years) and younger (<50 years) WLWH. As the only significantly different QoL component, bivariate analyses and linear regression were used to assess factors associated with physical HR-QoL of older women. Results: The sample frame comprised 1,422 women (28.0% older women). Younger WLWH's mean age was 37.8 years (SD = 7.4) compared to older WLWH (55.8 years, SD = 5.3). Compared to younger WLWH, older WLWH had poorer physical HR-QoL (40.0 vs. 50.7; p < 0.001) but similar mental HR-QoL (42.7 vs. 42.1; p > 0.001). Older WLWH had lower social support (p < 0.001) with no significant differences in depressive symptoms or resilience. Resilience was associated with improved physical HR-QOL. Food insecurity, poorer mental HR-QoL and depressive symptoms were associated with poorer physical health. Discussion: Compared to younger WLWH, older WLWH had poorer physical HR-QoL, which was associated with resilience, food insecurity and mental health factors, highlighting the complex interactions of health-related social-ecological factors impacting aging WLWH.

HIV Prevention Programming for Older African American Women: The Impact of a Faith-Based and Behavioral Science Partnership on Depressive Symptoms

Objective

The current study sought to test the effect of an HIV prevention intervention on depressive symptoms in a sample of older African American women.

Design Setting and Participants

A pretest-posttest randomized control group design was conducted in a mega-church in Los Angeles with a sample of 62 older African American women, aged ≥50 years, 29 of whom were randomly assigned to the experimental condition and 33 to the comparison/control condition.

Measures

A measure of psychological wellbeing (CES-D) was utilized to test the effect of the four-session group intervention vs the one-session informational group intervention on change in depressive symptoms from pretest to posttest. Demographic characteristics included: measures of age in years; relationship and employment statuses (coded 1 for yes, 0 for no); and educational attainment.

Results

Participation in the study was associated with a significant improvement in the women's psychological wellbeing from baseline to time 2; ie, decreased depressive symptoms. This change was greater for women in the four-session experimental group than for those in the one-session comparison group, due in part to a marginally significant interaction between time and experimental conditions.

Conclusions

This study demonstrates the utility of faith-based/behavioral-scientist partnerships in HIV programming. Findings contribute to the evidence on interventions that might reduce depressive symptoms and HIV risk among older African American women.

"We are becoming older women and then we have two stigmas": voicing women's biopsychosocial health issues as they age with HIV

In April 2019, nine older women (age 50+) living with HIV in Palm Springs, California, participated in a 90-minute focus group to identify their major health issues, strengths, and HIV and aging-related health priorities. Using the rigorous and accelerated data reduction (RADaR) technique, we identified four major themes: (1) mental health, (2) HIV comorbidities, (3) social determinants of health, and (4) resiliencies. These results reinforce the need to conduct additional research focused on women aging with HIV, an understudied population that requires more effective, tailored interventions to promote better quality of life and healthy aging.

Demographics and health profile on precursors of non-communicable diseases in adults testing for HIV in Soweto, South Africa: a cross-sectional study

OBJECTIVES

This cross-sectional study investigated the burden of HIV-non-communicable disease (NCD) precursor comorbidity by age and sex. Policies stress integrated HIV-NCD screenings; however, NCD screening is poorly implemented in South African HIV testing services (HTS).

SETTING

Walk-in HTS Centre in Soweto, South Africa.

PARTICIPANTS

325 voluntary adults, aged 18+ years, who provided written or verbal informed consent (with impartial witness) for screening procedures were enrolled.

PRIMARY AND SECONDARY OUTCOMES

Data on sociodemographics, tuberculosis and sexually transmitted infection symptoms, blood pressure (BP) (≥140/90=elevated) and body mass index (<18.5 underweight; 18.5-25.0 normal; >25 overweight/obese) were stratified by age-group, sex and HIV status.

RESULTS

Of the 325 participants, the largest proportions were female (51.1%; n=166/325), single (71.5%; n=231/323) and 25-34 years (33.8%; n=110/325). Overall, 20.9% (n=68/325) were HIV infected, 27.5% (n=89/324) had high BP and 33.5% (n=109/325) were overweight/obese. Among HIV-infected participants, 20.6% (14/68) had high BP and 30.9% (21/68) were overweight/obese, as compared with 29.3% (75/256) and 12.1% (31/256) of the HIV-uninfected participants, respectively. Females were more likely HIV-infected compared with males (26.5% (44/166) vs 15.1% (24/159); p=0.012). In both HIV-infected and uninfected groups, high BP was most prevalent in those aged 35-44 years (25% (6/24) vs 36% (25/70); p=0.3353) and >44 years (29% (4/14) vs 48% (26/54); p=0.1886). Males had higher BP than females (32.9% (52/158) vs 22.3% (37/166); p=0.0323); more females were overweight/obese relative to males (45.8% (76/166) vs 20.8% (33/159); p<0.0001). Females were more likely to be HIV infected and overweight/obese.

CONCLUSION

Among HTS clients, NCD precursors rates and co-morbidities were high. Elevated BP occurred more in older participants. Targeted integrated interventions for HIV-infected females and HIV-infected people aged 18-24 and 35-44 years could improve HIV public health outcomes. Additional studies on whether integrated HTS will improve the uptake of NCD treatment and improve health outcomes are required.

Understanding Comorbidities and Their Contribution to Predictors of Medical Resource Utilization for an Age- and Sex-Matched Patient Population Living With HIV: Cross-Sectional Study

BACKGROUND

More than 60% of people aging with HIV are observed to have multiple comorbidities, which are attributed to a variety of factors (eg, biological and environmental), with sex differences observed. However, understanding these differences and their contribution to medical resource utilization remains challenging as studies conducted exclusively and predominantly among males do not translate well to females, resulting in inconsistent findings across study cohorts and limiting our knowledge of sex-specific comorbidities.

OBJECTIVE

The objective of the study was to provide further insight into aging-related comorbidities, their associated sex-based differences, and their contribution to medical resource utilization, through the analysis of HIV patient data matched by sex.

METHODS

International Classification of Disease 9/10 diagnostic codes that comprise the electronic health records of males (N=229) and females (N=229) were categorized by individual characteristics, chronic and mental health conditions, treatment, high-risk behaviors, and infections and the codes were used as predictors of medical resource utilization represented by Charlson comorbidity scores.

RESULTS

Significant contributors to high Charlson scores in males were age (beta=2.37; 95% CI 1.45-3.29), longer hospital stay (beta=.046; 95% CI 0.009-0.083), malnutrition (beta=2.96; 95% CI 1.72-4.20), kidney failure (beta=2.23; 95% CI 0.934-3.52), chemotherapy (beta=3.58; 95% CI 2.16-5.002), history of tobacco use (beta=1.40; 95% CI 0.200-2.61), and hepatitis C (beta=1.49; 95% CI 0.181-2.79). Significant contributors to high Charlson scores in females were age (beta=1.37; 95% CI 0.361-2.38), longer hospital stay (beta=.042; 95% CI 0.005-0.078), heart failure (beta=2.41; 95% CI 0.833-3.98), chemotherapy (beta=3.48; 95% CI 1.626-5.33), and substance abuse beta=1.94; 95% CI 0.180, 3.702).

CONCLUSIONS

Our findings identified sex-based differences in medical resource utilization. These include kidney failure for men and heart failure for women. Increased prevalence of comorbidities in people living long with HIV has the potential to overburden global health systems. The development of narrower HIV phenotypes and aging-related comorbidity phenotypes with greater clinical validity will support intervention efficacy.

Older African Americans and the HIV Care Continuum: A Systematic Review of the Literature, 2003-2018

Evidence suggests that racial disparities in the HIV care continuum persist in older age groups, particularly among African Americans. The objective of this systematic review was to identify factors that facilitate or hinder older African Americans' engagement in the HIV care continuum. For studies published between 2003 and 2018, we: (1) searched databases using keywords, (2) excluded non-peer-reviewed studies, (3) limited findings to older African Americans and the HIV care continuum, and (4) retrieved and summarized data focused on barriers and facilitators of the HIV care continuum. Among the 1023 studies extracted, 13 were included: diagnosis/testing (n = 1), engagement in care (n = 7), and antiretroviral adherence (n = 5). Barriers included lack of HIV risk awareness, routine testing, and healthcare access, stigma, and multimorbidities. Social support, health/medication literacy, and increased self-efficacy facilitated engagement. A targeted focus on older African Americans is needed to achieve national goals of improving HIV care and treatment outcomes.

Examining age as a moderating effect on the relationship between alcohol use and viral suppression among women living with HIV

This study sought to examine if age moderated the effect of alcohol on viral suppression among women living with HIV. A secondary data analysis, using data from the 550 Clinic Women's HIV Cohort Study was completed. Individuals were included if they were HIV positive, sought care in an urban clinic in Kentucky between 2009 and 2012, and had ≥1 year of follow-up. The primary independent variable was current alcohol use; the moderating variable was age (<50 years versus ≥50 years); and the outcome was suppression. Logistic regression models examined the interaction between age and alcohol. Among 360 women (average age 45.8 ± 10.1 years, 38 percent were ≥50 years), approximately 32.0 percent had consumed alcohol, and 40 percent achieved suppression. Women aged ≥50 years were more likely to achieve suppression than younger women. Age interacted significantly with alcohol (p = .038). Stratified by age, alcohol was associated with poor viral suppression among older women; for older women, alcohol users had lower odds of suppression compared to nonusers (odds ratio = 0.37; 95 percent confidence interval = 0.14-0.99). Alcohol may impede the opportunity for older women to achieve suppression. Further study is needed to examine alcohol use among older women, specifically addressing quantity and frequency and their impact on suppression.

“I Don’t Know and I Don’t Want to Know”: A Qualitative Examination of Older African American Women’s Knowledge and Experiences With HIV

While older African American women (e.g., aged 50 years and older) comprise only 11% of the female population in the United States, they account for 50% of HIV diagnoses among women in this age group. Unique sociocultural factors, including a lack of HIV knowledge and stigma, contribute to HIV risk among older African American women. The goal of this qualitative study was to obtain a nuanced perspective from older African American women about HIV knowledge and experiences with HIV using the framework of intersectionality theory. Focus groups were conducted with 35 African American women who were 50 years and older, nonpartnered, and heterosexual. Women were asked what they knew about HIV and if they thought older women were at risk for HIV. A thematic analysis using NVivo 11 yielded two central themes and three subthemes: HIV knowledge, including experiential knowledge, superficial knowledge, and no knowledge, and stigma around HIV in the Black church. Implications for developing HIV prevention programs and testing messages are discussed.

Factors associated with testing for HIV in people aged ≥50 years: a qualitative study

Background

Despite a decline in the number of new HIV infections in the UK overall, the number and proportion of new HIV diagnoses in people aged ≥50 years continues to increase. People aged ≥50 years are disproportionately affected by late diagnosis, which is associated with poorer health outcomes, increased treatment complexity and increased healthcare costs. Late HIV diagnosis also has significant public health implications in terms of onward HIV transmission. It is not fully understood what factors affect the decision of an older person to test for HIV. The aim of this study was to identify factors associated with testing for HIV in people aged ≥50 years who tested late for HIV.

Methods

We interviewed 20 people aged ≥50 years diagnosed late with HIV to identify factors associated with HIV testing. Interviews were audio recorded, transcribed verbatim and thematically analysed.

Results

Seven themes associated with HIV testing in people aged ≥50 years were identified: experience of early HIV/AIDS campaigns, HIV knowledge, presence of symptoms and symptom attribution, risk and risk perception, generational approaches to health and sexual health, stigma, and type of testing and testing venue.

Conclusion

Some factors associated with testing identified in this study were unique to older individuals. People aged ≥50 years often do not perceive themselves to be at risk of HIV. Further, stigma and a lack of knowledge of how to access HIV testing suggest a need for health promotion and suggest current sexual health services may need to adapt to better meet their needs.

Sexual Health Behavior and Mental Health Among Older African American Women: The Sistahs, Sexuality, and Mental Health Well-Being Project

BACKGROUND

In Los Angeles County, the rates of sexually transmitted infections and diseases among African Americans represent a significant public health disparity. Older African American women are at particular risk as they are more likely to engage in high-risk sexual behaviors and report social isolation and loneliness than their younger counterparts. However, the literature on the relationship between sexual health and mental health in this group is limited. The purpose of this study was to use a community-based participatory research (CBPR) approach to better understand sexual health behaviors and mental health among African American women over 50 years of age who reside in South Los Angeles.

MATERIALS AND METHODS

This project was divided into two phases. Phase I (January-March 2017) of the project consisted of four dialog/focus groups (N = 45) (ages: 50-80; M_age = 67). The purpose of Phase II (April 2017) was to present study results from Phase I to the community via a community-based conference, as well as gather feedback and generate discussion about the next steps for community prevention/intervention.

RESULTS

Women reported that they did not feel comfortable discussing sexual practices with their physician, partners, and friends. Most women identified depression, loneliness, and self-esteem issues as reasons for engaging in high-risk sexual behaviors. During Phase II, potential intervention avenues emerged to address issues such as lack of physician-patient communication, lack of community support, and dialogs about sex.

CONCLUSIONS

The use of CBPR greatly enhanced our knowledge of the core issues surrounding sexual health and mental health among older African American women.

Qualitative longitudinal study of episodic disability experiences of older women living with HIV in Ontario, Canada

OBJECTIVES

To examine the episodic disability experiences of older women living with HIV over time.

DESIGN

Qualitative longitudinal study, conducting semistructured in-depth interviews on four occasions over a 20-month time frame. Inductive thematic analyses were conducted cross-sectionally and longitudinally.

SETTING

Participants were recruited from HIV community organisations in Canada.

PARTICIPANTS

10 women aged 50 years or older living with HIV for more than 6 years.

RESULTS

Two major themes related to the episodic nature of the women's disability. Women were living with multiple and complex sources of uncertainty over time including: unpredictable health challenges, worrying about cognition, unreliable weather, fearing stigma and the effects of disclosure, maintaining housing and adequate finances, and fulfilling gendered and family roles. Women describe strategies to deal with uncertainty over time including withdrawing and limiting activities and participation and engaging in meaningful activities.

CONCLUSIONS

This longitudinal study highlighted the disabling effects of HIV over time in which unpredictable fluctuations in illness and health resulted in uncertainty and worrying about the future. Environmental factors, such as stigma and weather, may put older women living with HIV at a greater risk for social isolation. Strategies to promote dealing with uncertainty and building resilience are warranted.

Virologic failure and mortality in older ART initiators in a multisite Latin American and Caribbean Cohort

INTRODUCTION

The "greying" of the HIV epidemic necessitates a better understanding of the healthcare needs of older HIV-positive adults. As these individuals age, it is unclear whether comorbidities and their associated therapies or the ageing process itself alter the response to antiretroviral therapy (ART). In this study, HIV treatment outcomes and corresponding risk factors were compared between older ART initiators and those who were younger using data from the Caribbean, Central and South America Network for HIV Epidemiology (CCASAnet).

METHODS

HIV-positive adults (≥18 years) initiating ART at nine sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru were included. Patients were classified as older (≥50 years) or younger (<50 years) based on age at ART initiation. ART effectiveness was measured using three outcomes: death, virologic failure and ART treatment modification. Cox regression models for each outcome compared risk between older and younger patients, adjusting for other covariates.

RESULTS

Among 26,311 patients initiating ART between 1996 and 2016, 3389 (13%) were ≥50 years. The majority of patients in both ≥50 and <50 age groups received a non-nucleoside reverse transcriptase inhibitor-based regimen (89% vs. 87%), did not have AIDS at baseline (63% vs. 62%), and were male (59% vs. 58%). Older patients had a higher risk of death (adjusted hazard ratio (aHR) 1.64; 95% confidence intervals (CI): 1.48 to 1.83) and a lower risk of virologic failure (aHR: 0.73; 95% CI: 0.63 to 0.84). There was no difference in risk of ART modification (aHR: 1.00; 95% CI: 0.94 to 1.06). Risk factors for death, virologic failure and treatment modification were similar for each group.

CONCLUSIONS

Older age at ART initiation was associated with increased mortality and decreased risk of virologic failure in our cohort of more than 26,000 ART initiators in Latin America and the Caribbean. To the best of our knowledge this is the first study from the region to evaluate ART outcomes in this growing and important population. Given the complexity of issues related to ageing with HIV, a greater understanding is needed in order to properly respond to this shifting epidemic.

Life begins at 60: Identifying the social support needs of African American women aging with HIV

HIV chronicity has resulted in increased life expectancy for many African American women who acquired the disease during the epidemic's peak years. As these women live longer and age, their social support needs may increase. Five focus groups were conducted in Washington, DC with 23 HIV-positive African American women aged 52-65 to explore women's perceptions about how aging and HIV chronicity affects their social support needs. Participants were recruited from the longitudinal Women's Interagency HIV Study (WIHS) participant pool. A constant comparison approach was applied during data analysis. Participants reported needing increased social support, especially emotional support from health care providers, family, and HIV-positive peers. The importance of providers and HIV-positive peers was discussed most frequently relative to meeting these needs. Health care providers in particular may need to increase their provision of emotional support when devising treatment plans to meet the social support needs of older HIV-positive African American women.

Strategies for improving the lives of US women aged 40 and above living with HIV/AIDS: an evidence map

BACKGROUND

While in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri- and postmenopausal women.

METHODS

We conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS.

RESULTS

Of these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.

CONCLUSION

The evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

HIV and Aging Research in Women: An Overview

This paper reviews some background issues as a foundation to place the ensuing supplement papers of this special issue section in context. The articles in this special supplement issue deepen and expand our understanding of biomedical, neurocognitive, and psychosocial aspects involved in human immunodeficiency virus (HIV) of older women, primarily through the use of the Women's Interagency HIV Study (WIHS) prospective cohort study. As it relates to research on the intersection between HIV and aging in women, we discuss (i) epidemiology as introduction, (ii) the cohort study design featuring the WIHS, (iii) definitions, (iv) models, and (v) section articles.

Barriers and facilitators to HIV testing in people age 50 and above: a systematic review

Approximately 13% of people living with HIV in the UK are unaware of their infection. New diagnoses among people ≥50 years is increasing. Unique factors may be associated with testing in this group. This systematic review aims to identify patient and clinician-related barriers/facilitators to HIV testing in people aged ≥50 years. A systematic electronic search was conducted. Papers were assessed for eligibility and data from eligible studies were extracted. Barriers/facilitators were grouped, and the number of times they were reported was noted. Because of considerable heterogeneity, a narrative approach has been undertaken to synthesise data. In total, 17 studies were included. Main barriers to testing were low perceived risk and clinicians' preconceptions about older people. Main facilitators were regular use of healthcare services or being offered/encouraged to test by a healthcare provider. Although being encouraged to test was a common facilitator, clinicians' preconceptions about older people was the biggest barrier. This shows a divide between clinicians' preconceptions and patients' expectations, which may impact on testing rates. This review is an important first step in identifying potential barriers/facilitators for further study or to be addressed in the design of future interventions.

HIV Risk, Substance Use, and Personality Characteristics among Adults with History of Serious Mental Illness

The present study examined the relationship between characteristics associated with personality disorders, substance use, and HIV risk among adults with a history of serious mental illness. Participants included 103 adults with antisocial or borderline personality disorder, serious mental illness, and recent HIV risk behavior. The sample was predominately male (64%), diverse (42% African American and 13% Hispanic), and homeless/marginally housed (76%). In order to examine the relationship between personality characteristics and risk we constructed a risk index comprising key symptoms of antisocial and borderline personality disorders, namely; impulsivity, affective instability, and disregard for safety of self/others. Contrary to our primary hypotheses, risk index scores did not predict HIV risk behavior and substance abuse did not mediate this risk. Exploratory analyses did reveal that women engaged in significantly more risk behaviors than their male counterparts and that risk scores were a significant predictor of total sex acts for women but not men. In addition, increased emotional dysregulation was a significant predictor of condomless sex acts for women but not men. Finally, recent alcohol use and increased impulsivity was associated with more condomless oral sex for men and women. These results suggest the relationship among serious mental illness, personality disorder, substance abuse, and gender is complex and merits further study.

Women 50 and Older and HIV: Prevention and Implications for Health Care Providers

The current article discusses the importance of implementing HIV and AIDS education, prevention, and intervention programs that are tailored to women 50 and older and to determine HIV risk factors for this population. A literature search was performed, resulting in 41 relevant articles. The literature underscored the significance of increasing awareness of HIV/AIDS, particularly among older women. HIV risk behaviors and the effect that these behaviors have on HIV transmission and prevention among women 50 and older are described. Prior research findings identified risk categories of older women that may contribute to the transmission of HIV among this particular population, including heterosexual relations, perceived HIV risk, ageism and HIV transmission, biological factors, transfusions, sexual enhancement aids, and health care providers and prevention messages. In addition, previous findings indicate that health care providers have not traditionally targeted women 50 and older for HIV prevention. Health care providers should incorporate discussion of HIV risk and transmission during clinic visits and implement prevention programs that target this population. [Journal of Gerontological Nursing, 43(12), 29-34.].

Woman to Woman (W2W): Adapting an HIV risk reduction intervention for older women

Woman to Woman (W2W) is a novel adaptation of the Sisters Informing Sisters about Topics on AIDS (SISTA) HIV prevention program. This article describes the process of adapting and piloting W2W based on recommendations from existing HIV prevention research. Six older women, all of whom had histories of homelessness and the majority of whom identified as African American, enrolled in the study, which piloted the adapted intervention and materials, evaluated the acceptability of the program, and assessed the measures related to the intervention. Participants described satisfaction with the program and had high rates of attendance; observations regarding the measures suggest the need to further develop assessments of HIV knowledge, condom use self-efficacy, and risk behaviors in this context.

Healthy Aging in Older Women Living with HIV Infection: a Systematic Review of Psychosocial Factors

Due to life-enhancing effects of antiretroviral therapy, HIV-positive persons have the potential for long life comparable to their uninfected peers. Older women (age 50+) living with HIV (OWLH) are often an under-recognized aging group. We conducted a systematic review to examine psychosocial factors that impact how OWLH live, cope, and age with HIV. Initial key word search yielded 1527 records, and 21 studies met our inclusion criteria of original quantitative or qualitative research published between 2013 and 2016 with results specific to OWLH. These focused on health care and self-management, sexual health and risk, stigma, loneliness, mental health (depression, substance use), and protective factors (coping, social support, well-being). Due to the scarcity of studies on each topic and inconclusive findings, no clear patterns of results emerged. As the number of OWLH continues to grow, more research, including longitudinal studies, is needed to fully characterize the psychosocial factors that impact aging with HIV.

A Comparison of Actual and Perceived Sexual Risk Among Older Adults

Sexual risk among older adults (OAs) is prevalent, though little is known about the accuracy of sexual risk perceptions. Thus, the aim was to determine the accuracy of sexual risk perceptions among OAs by examining concordance between self-reported sexual risk behaviors and perceived risk. Data on OAs aged 50 to 92 were collected via Amazon.com's Mechanical Turk. Frequency of sexual risk behaviors (past six months) were reported along with perceived risk, namely, sexually transmitted infection (STI) susceptibility. Accuracy categories (accurate, underestimated, overestimated) were established based on dis/concordance between risk levels (low, moderate, high) and perceived risk (not susceptible, somewhat susceptible, very susceptible). Approximately half of the sample reported engaging in vaginal (49%) and/or oral sex (43%) without a condom in the past six months. However, approximately two-thirds of the sample indicated they were "not susceptible" to STIs. No relationship was found between risk behaviors and risk perceptions, and approximately half (48.1%) of OAs in the sample underestimated their risk. Accuracy was found to decrease as sexual risk level increased, with 93.1% of high-risk OAs underestimating their risk. Several sexual risk behaviors are prevalent among OAs, particularly men. However, perception of risk is often inaccurate and warrants attention.

Prevalence and correlates of psychological distress of middle-aged and older women living with HIV

The aims of this study were to examine the prevalence and correlates of psychological distress among older women living with HIV in comparison to their male counterparts and younger women and to identify the sociodemographic and disease-related factors associated with psychological distress. The sample consisted of 508 HIV-infected patients (65 older women, 323 women aged below 50 years, and 120 older men) recruited from 10 Portuguese hospitals. Data regarding psychological distress were collected using the Brief Symptom Inventory (BSI). Seven older women (10.8%), eight older men (6.7%), and 61 younger women (18.9%) reported a T-score ≥ 63 for global severity index (GSI), indicative of a need for further psychological evaluation. Overall, younger women reported significantly higher psychological distress than older men. The odds of having clinically significant psychological distress score were significantly lower for older women reporting sexual transmission, while for younger women, having other co-infections was a significant correlate of higher psychological distress. Younger women were 2.67 (95% CI: 1.22-5.84) times more likely to report psychological distress than were older men. The odds were not significantly different from older women. This study shows that older women do not differ substantially from younger women and older men in terms of psychological distress. The results reinforce, however, that mental health interventions should be tailored to reflect individuals' circumstances as well as developmental contexts. Moreover, they draw attention to the importance of examining resilience characteristics in older adults to understand the mechanisms behind 'successful ageing' while living with HIV.