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Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Current Knowledge and Future Directions on Aging and HIV Research Charles A. Emlet
a
a
University of Washington Tacoma Published online: 04 Aug 2014.
Click for updates To cite this article: Charles A. Emlet (2014) Current Knowledge and Future Directions on Aging and HIV Research, Behavioral Medicine, 40:3, 143-148, DOI: 10.1080/08964289.2014.935235 To link to this article: http://dx.doi.org/10.1080/08964289.2014.935235
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
BEHAVIORAL MEDICINE, 40: 143–148, 2014 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print/1940-4026 online DOI: 10.1080/08964289.2014.935235
CONCLUSION
Current Knowledge and Future Directions on Aging and HIV Research Downloaded by [Flinders University of South Australia] at 14:47 07 February 2015
Charles A. Emlet University of Washington Tacoma
In 2012, the National Institutes of Health (NIH) Office of AIDS Research, through the HIV and Aging Working Group developed a document entitled HIV and Aging: State Of Knowledge and Areas of Critical Need For Research.1 The goal of the report was to “assess what is known and unknown and what the priorities should be for research at the interface of HIV, aging, and multimorbidity.”(pS2) The importance of this agenda is underscored by the often cited figure that by the year 2015, half of all people living with HIV in the US will be age 50 or over.1 More recently, another projection suggests that by 2020 approximately 70% of those living with HIV disease in the United States will be over the age of 502—a sobering statistic. The research priorities articulated in the Working Group report, along with the articles in this issue of Behavioral Medicine, help point the way for the current pulse, as well as future directions of aging and HIV research. The articles contained in this issue represent a slice of the diversity of research, thematically and methodologically, that is being conducted in the area of aging and HIV at this point in time. The six articles contained herein cover several important areas of inquiry, including: substance use (including tobacco and illicit drugs), teletherapy related to depression treatment and the lowering of sexual risk behavior, and two articles that recognize the diversity and heterogeneity of this population including older women and older Latino/as. The purpose of this article is to briefly summarize the six research studies contained in this issue of Behavioral Medicine and provide some thoughts and suggestions for future research.
Correspondence should be addressed to Charles A. Emlet, PhD, MSW, University of Washington Tacoma, 1900 Commerce St., Campus Box 358425, Tacoma, WA 98402-5825, USA. E-mail: [email protected]. edu
OLDER ADULTS LIVING WITH HIV AND SUBSTANCE USE As discussed in the report by the Working Group,1 substance use has played a critical role in HIV through both direct transmission behaviors (injection drug use) and secondary transmission whereby substance use increases risk behaviors associated with HIV infection. Older adults living with HIV are more likely than their HIV negative counterparts to continue substance abuse including tobacco, alcohol, opioids, and other substances.3 Numerous studies have found that individuals of all ages who are HIV-positive are more likely to use tobacco.4 For example, Fredriksen-Goldsen and colleagues,5 in a study of 2,650 lesbian, gay, bisexual, and transgender older adults found those with HIV were significantly more likely to smoke tobacco than their HIV negative counterparts. Due to the high risk of smoking behavior among older adults living with HIV, it is critical we better understand the impact of tobacco on comorbidities, and treatment outcomes as suggested by the NIH panel.1 Ompad and colleagues report on the relationship between smoking among older HIV-positive adults and various health outcomes. The health outcomes in this study were specific to factors associated with HIV disease including medication adherence and rates of opportunistic infections (OIs). This study, focusing specifically on a sample of older gay and bisexual men, as well as other men who have sex with men (N D 199), found that 70% were current or former smokers. Smoking was associated with other behaviors that may impact health such as a higher likelihood of illicit drug use. Additionally, older adults living with HIV who currently smoke were found to have characteristics associated with poorer health outcomes and clinical markers specifically related to HIV management. For example, smokers were significantly less likely to report
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an undetectable viral load than either former smokers or nonsmokers, and were more likely to have CD4 cell counts less than 500 cell/ml. The researchers of this study also found smoking to be related to negative impacts on other HIV related health outcomes. Smoking was significantly associated having been diagnosed with an OI at some point in time, while current and former smokers were more likely than nonsmokers to have reported a respiratory OI in their lifetime. Smokers were more likely to have candidiasis and PCP, and were significantly more likely to report a gastrointestinal OI. We know smoking has a negative impact on all people, but the results of this study suggest the impact may be more severe for HIV-positive individuals, particularly in regard to HIV-related health outcomes. Smoking clearly needs to be considered as part of any array of substance-use assessments, and the importance of cessations programs for HIVpositive individuals should be carefully considered as part of primary or secondary prevention activities. The research by Brennan-Ing, Porter, Seidel, and Karpiak presented in this issue extends the focus on substance use and its impact on older adults living with HIV disease. These researchers used data from the ROAH (Research on Older Adults with HIV) study6 to examine the role of substance use and sexual risk behavior among 239 older gay and bisexual men. This article sets an important stage, first by acknowledging the heterogeneity that exists within older adults living with HIV; recognizing, in this instance, potentially important differences between gay and bisexual men. As more data on LGBT older adults becomes available through scientific studies7 we can better understand important differences between subgroups of sexual minorities. As previously mentioned, substance use can result in an increase is sexual risk behavior,1 and this study sought to enlighten our understanding of differences in substance use between older gay and bisexual older men (living with HIV) and whether substance use is associated with unprotected intercourse. There is clear evidence that substance use patterns differ between HIV-positive individuals and their HIV negative peers.5,8 What is perhaps less clear, are differing patterns of substance use among HIV-positive gay versus bisexual men (these two populations are often merged in HIV research). The results of this study confirm significant and substantial differences between these two groups. For example, the researchers found bisexual men were more likely to be current smokers, and were more likely to endorse using tobacco, cocaine, crack cocaine and heroin than their gay counterparts. Gay men in this sample, however, were significantly more likely to use crystal meth, club drugs, poppers, and erectile dysfunction medications. With regard to sexual risk behavior, sexual orientation was not significant in the final regression analysis, however current use of ED medications and use of poppers resulted in increased odds of unprotected sex.
This study brings to light important differences between older gay and bisexual men. The study noted a number of differences in substance use patterns between these two groups, differentiated by the types of drugs in question. Recent research has, for example, documented important differences between older gay and bisexual men including higher risk for cardiovascular disease, stress, and loneliness among bisexual men.5 As the authors of this study suggest, recognizing differences between older gay and bisexual men is critical to sound assessment of risk as well as service provision, and it is important that providers do not make assumptions about similarities between these populations based on the sex of their sexual partners. Brennan-Ing and colleagues go on to reinforce the importance of recognizing group differences in conducting research. It is common, for example, for researcher to collapse these two groups due to small sample sizes. While such an approach can be methodologically necessary, the limitation of not differentiating between gay and bisexual men must be recognized as a limitation. At the same time, researchers need to consider syndemic theory, the overlapping and reinforcing of health problems9 in the older adults. Recently, Halkitis and colleagues9 have applied syndemic theory to a population of older HIV-positive gay, bisexual, and other MSM reinforcing the complexity of substance use and other areas of health. MENTAL HEALTH AND ASSOCIATED PSYCHOSOCIAL ISSUES The rapidly expanding literature on aging and HIV (see the introduction in this issue) has documented the variety of mental health and psychosocial issues impacting this population. Many of these mental health and psychosocial issues are highly interrelated. For example, social isolation and loneliness are associated with depression1 and stigma10 among older HIV-positive adults. Lower levels of social support have been associated with increased HIV stigma11 and lessened mental health quality of life among older, HIV-positive gay and bisexual men.12 Additionally, older adults face layering from HIV stigma, ageism, and other characteristics that may be stigmatized by society such as racial and ethnic background or HIV-risk behaviors.13 As pointed out by the HIV and Aging Working Group,1 research in this area must work toward enhancing our understanding of the sociobehavioral influences that impact aging and HIV in order to improve positive outcomes. The NIH report points out a clear objective that studies focusing on the mental health needs of this population and potential interventions need to be encouraged. Two articles contained in this issue do exactly that. They seek to improve our understanding of treatment approaches to mental health issues in this population through randomized control trials (RCT).
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CONCLUSION
The first RCT study conducted by Heckman and colleagues sought to determine the acceptability and efficacies of two types of teletherapy treatments for depression among groups of older MSM and heterosexuals living with HIV disease. For this study, 361 older adults were recruited from 24 states. A score of 10 or greater on the Geriatric Depression Scale (30-item version) was required for participation. Groups based on sexual orientation were assigned to telephone coping effectiveness training, telephone supportive-expressive group therapy, or a standards of care control. The study sought to assess the impact of these teletherapy formats on depressive symptoms among the two differing populations of older HIV-positive adults. The researchers point out that teletherapy may be particularly efficacious for delivering therapy in light of potential privacy concerns associated with experiences of stigma and discrimination. With regard to the session attendance, MSM attended slightly more session in both categories of the treatment arm than their heterosexual counterparts, however differences were not statistically significant. This study found important differences in the efficacy of treatment for depression based on sexual orientation. In the MSM group, significantly fewer depressive symptoms were reported in the supportive, expressive group therapy post intervention compared to the standards of care group. The same pattern is true for heterosexuals in the same treatment condition, however in the heterosexual group, those lowered depressive symptoms were maintained at 4month and 8-month follow up intervals (not so for the MSM group). This research points to important concerns about the mental health needs and treatment of depression among older adults living with HIV disease. While supportive expressive group therapy was effective in reducing depressive symptoms, improved treatment outcomes were more likely to dissipate among the MSM group over time. These differences existed despite the fact that those in the MSM groups attended slightly more sessions of both treatment arms than their heterosexual counterparts. The findings from this study have two important take-away messages. First, that in an RCT, supportive expressive therapy is effective in reducing depressive symptoms in the populations studied. Second, the results again highlight the diversity and heterogeneity that exists within the population of older adults living with HIV disease and potentially the effectiveness of treatment over time. Lovejoy and colleagues examined the impact of depression on treatment efficacy related to secondary prevention designed to reduce sexual risk behavior. There is clear evidence establishing links between depression with sexual risk behaviors in HIV-positive persons.13 Researchers recruited a total of 100 individuals, age 45 or older, from five metropolitan areas of the Eastern and Midwestern
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United States. Individuals were assigned to a 4-session telephone motivational interviewing (“tele-MI”) condition, a 1session tele-MI condition using the same approach, or standards of care. Study results reinforce that midlife and older adults living with HIV not only continue to be sexually active, but engage in sexual risk behavior. Half (49%) reported engaging in non-condom protected sex with HIV-positive persons in the previous three months and 59% reported sexual relationships with one or more casual/anonymous sexual partners in the previous three months. Regarding the impact of depression on sexual risk behavior, respondents with lower depressive symptoms had the highest level of non-condomprotected anal and vaginal sex acts (10.6) compared to those with higher depression (4.7) or no depressive symptoms (7.3). When the efficacy of the 4-session tele-MI was examined by depression levels, important and interesting patterns emerged. For example, those with no depressive symptoms had fewer episodes of non-condom-protected sex compared to the other two treatment arms. What is also important to consider, however, is that those differences were not sustained at the 6-month follow up. Those individuals with low levels of depressive symptoms (and the highest rate of non-condom-protected sex) at baseline, had a greater decrease in the target behaviors at both 3and 6-month follow ups. Those with high depressive symptoms did not differ from other participants at 3- or 6month follow up. Mental health issues, particularly depression, can seriously impact the lives of older persons living with HIV in a myriad ways. The two studies just discussed identified depression and other characteristics as important factors to consider. In the first study, we learned of the impact sexual orientation may have not only in willingness to be involved in treatment, but treatment efficacy. Second depression based on levels of symptomatology, can impact the efficacy of secondary prevention strategies for reducing non-condom protected sex among midlife and older adults. Recently, Halkitis and colleagues found depression to be associated with poorer antiretroviral therapy adherence in a sample of 180 HIV-positive MSM in New York City.15 The mental health studies in this issue, along with other recent research, reinforce the impact depression and other mental health issues can have on older HIV-positive adults. Treatment adherence and efficacy of secondary prevention strategies can be impacted by depressive symptoms. We also know from the research published in this issue, that the efficacy of treatment for depression may be impacted by sexual orientation. How gender, sexual orientation, and other psychosocial factors impact depression treatment and how depressive symptoms can impact HIV adherence and psychosocial stability are all areas needing to be unraveled in future research.
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AT-RISK POPULATIONS WITHIN HIV-POSITIVE OLDER ADULTS Older adults living with HIV are a diverse and heterogeneous group. People living with HIV represent gender and racial minorities who are continually confronted by social and economic constraints.1 Recognizing the diversity within the older adult population, it is important to construct an aggressive research agenda that will enlighten not only what we know about different groups, but how we come to understand this information. Two groups of older adults who receive minimal research consideration are women and Latino/as. The older Hispanic population is disproportionally impacted by HIV disease.16 Older women are also at increased risk for HIV infection due to physiologic changes and social stigma and views on sexuality.17 Durvasula provides an important scholarly overview of issues facing older women living with HIV disease. The authors point out that little research has focused specifically on older women living with HIV despite the fact that they must contend with differing physical, psychological and psychosocial burdens. Older women living with HIV are often invisible due to myths about aging, sexuality, and risk. Unfortunately, both older women themselves as well as service providers lack understanding, thus contributing to a lack of testing and treatment. For example, younger providers may feel embarrassment talking with older women about sexuality or sexual risk and carry ageist beliefs about sexuality and older women. Due to this lowered perception of risk or insufficient screening, less testing can result in delayed diagnosis and treatment. Older women are more likely to not be in a committed relationship compared to their younger counterpart and the dynamics of negotiating safe sexual relationships can add to risk. Additionally, older women face issue of interpersonal violence, which contributes to HIV risk due to multiple partners, STI risk, and greater risk behavior among their partners. Too often, the resulting consequences of these risks include isolation, which creates its own set of mental health and psychosocial problems as discussed earlier. Durvasula points to the importance of physical care that is specific to older women; specifically, the interplay between HIV and menopause is of concern and further research in this area is needed. Additionally, the side effects of cART and that HIV symptoms can mimic age related comorbidities that can be more pronounced in older women. Older women also face a variety of neuropsychiatric issue that compound HIV. One study18 found 67% of older women reported an Axis I diagnosis compared to 50% of younger women. In addition, multiple threats to cognitive function may exist; including HIV, substance abuse, and age associated cognitive decline. In addition to the psychological, social, and physical elements of HIV in older women, the authors point out the importance of narratives in the lives of these older women
and in particular stories of coping and resilience. At the beginning of the article, the author introduces Yolanda, a 50 year old woman living with HIV since 1989. Through transition and growth HIV has “given her life meaning and community.” Murphy and colleagues19 have documented the hopes of HIV-positive women including change in life focus, self-improvement, romantic partners, and developing and healing family ties. In addition to the need for clinical trials and rigorous quantitative research, we also need to build on narrative approaches that may focus on resilience and move away from deficit based models building on the multiple strengths that exist in this population. The final article herein again focuses on the heterogeneity of the population of older adults living with HIV; specifically older Latina/o adults. According to the CDC, infection rates among Hispanics/Latinos in 2010 in the United States was more than 3 times as high as that of whites.16 Researchers and policymakers are being called on to better address the needs of older LGBT adults and older people of color living with HIV.20 People of all ages, particularly older adults, living with HIV are at risk for cognitive impairment including HIV associated neurocognitive disorders (HAND) and HIV associated dementia. In this study, Rivera Mindt and colleagues utilized a sample of 126 older and younger Latinas/os and Non-Hispantic Whites (NHW) to determine if Latinas/os are at risk for worsened neurocognitive outcomes than their NHW counterparts within the context of HIV and aging. The 126 participants (84 Latina/o and 42 NHW adult were recruited for a parent study in the Spanish Harlem neighborhood of New York City and ranged in age from 18–80. Those under 50 (n D 82) were considered younger while those over 50 (n D 44) were considered older. The results from the study suggest important differences and risk associated both with racial and ethnic background and age. For example, they found both older and younger Latino/as were more likely to have an AIDS diagnosis and more likely to have a detectable viral load as compared to the NHW counterparts. These findings raise concern for the potential of later diagnosis, poorer efficacy with medications or other contributing factors. When comparing the older age group only, Latino/as demonstrated mild impairment in learning and mild to moderate impairment of memory. No such impairments were found in the NHW group. The findings from this study suggest that even after controlling for relevant covariates, Latina/o ethnicity may put one at higher risk for HAND. We know from other research that US Latina/os suffer from health disparities outside of HIV. Whether these processes are linked needs further investigation. MOVING FORWARD The six articles included in this issue of Behavioral Medicine reflect the diverse populations of older adults impacted
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CONCLUSION
by HIV disease and the wide range of issues that confront people living with HIV, service providers and researchers. These studies address many of the areas needing further research outlined by the HIV and Aging Working Group. As the population of older adults living with HIV disease grows, the opportunity exists to conduct research, both quantitative and qualitative with more diverse populations and using larger sample sizes that are more geographically diverse. It is important to consider that individuals within this population exist within multiple and complex identities including sexual orientation and gender identity, racial and ethnic background, HIV cohort,24 socioeconomic status, rural versus urban residence, and many other factors that shape their experience and relationship with HIV. One area outlined by the working group that deserves specific mention is that of successful aging with HIV. It is important to encourage and foster research that emphasizes positive psychology, mindfulness, hardiness, and resilience, and to translate those findings to help those not successfully aging with HIV.1 While there is a growing body of research in the areas of successful aging and in resilience in people living with HIV, a combined focus is needed. Vance and colleagues21 has done important work in the area of hardiness, and recent research has focused on strengths and resilience in older HIV-positive adults.22 Recently, Emlet and colleagues conduced 30 in-depth interviews with older adults living with HIV in Ontario, Canada, focusing on successful aging. Many of the emerging themes from that research show strong relationships to the areas suggested by the HIV and Aging Working Group including the importance of mindfulness, spirituality, mastery, and resilience.23 In his groundbreaking book The AIDS Generation, Halkitis communicates the importance of resilience in the lives of midlife and older MSM who have been living with HIV for many years.24 Future research needs to begin to deepen our understanding of successful aging with HIV and how theoretical models for successful aging from the gerontological literature can be adapted to this specific population. Are characteristics associated with successful aging with HIV innate or learned? Are those traits or characteristics teachable? Can they be learned through intervention research? Future research can begin to move our embryotic understanding of this phenomenon to a more refined position whereby interventions can be developed and tested to improve individual responses to aging with HIV. As already mentioned, the increasing number of older adults living with HIV disease will expand our opportunity to conduct rigorous research with larger sample sizes and robust methodologies. Durvasula also points to the importance of understanding their lives through narratives. Some populations (as she suggests older women) are more amenable to engaging in research that focuses on the person’s individual lived experience. While we have learned a tremendous amount in the past few years, and the numbers of published research studies has grown dramatically, there is
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still a place for qualitative, narrative analysis capturing the lived experiences of this diverse population. A recent policy statement from the Diverse Elders Coalition19 also helps suggest future directions in aging and HIV research. The policy recommendations maintain that older adults living with HIV continue to be a profoundly understudied population in biomedical, clinical, and social science disciplines, and that the NIH should be appropriately funded to support this important research agenda. The Coalition also suggests that the NIH support funding priorities outlined in the HIV and Aging Working Group document, including but not limited to behavioral health and supportive resources. Consistent with the articles in this issue, that policy recommendation specifically identifies research funding to improve our understanding of HIV among older women, LGBT older adults, and communities of color.19 In addition to biomedical and social science research, the community of researchers and advocates needs to move this agenda into the policy arena, including the upcoming White House Conference on Aging and programming from the Older American’s Act. These improvements in aging policy will pave the way for research to address the tailoring and acceptability of services aimed at older adults living with HIV disease. This special issue of Behavioral Medicine significantly contributes to furthering and informing research on aging and HIV. The wide spectrum of research needed within this heterogeneous population was underscored by the variety of studies contained in this issue. As we move into the next decade and beyond, HIV and aging research will both be challenged by the overwhelming complexity of the topic and be motivated to contribute to this landscape of knowledge which changes constantly.
REFERENCES [1] High KP, Brennan-Ing M, Clifford DB, et al. HIV and aging: state of knowledge and areas of clinical need for research. A report to the NIH office of AIDS Research by the HIV and Aging Working Group. JAIDS. 2012;60: S1–S18. [2] Senate Special Committee on Aging. Testimony of Daniel Tietz. Older Americans: The changing face of HIV/AIDS in America. Report of the Senate Special Committee on Aging, 113th Congress; 2013. [3] Green TC, Kershaw T, Lin H, et al. Patterns of drug use and abuse among aging adults with and without HIV: a latent class analysis of a US veteran cohort. Drug Alcohol Depend. 2010;110:208–220. [4] Shuter J, Bernstein SL. Cigarette smoking is an independent predictor of nonadherence in HIV-infected individuals receiving highly active antiretroviral therapy. Nicotine Tob Res. 2008;10:731–736. [5] Fredriksen-Goldsen KI, Kim H-J, Emlet CA, et al. The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle, WA: Institute for Multigenerational Health. 2011. Retrieved from http://depts.washington.edu/ agepride/wordpress/wpcontent/uploads/2011/05/Full-Report-FINAL. pdf
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[6] Brennan M, Karpiak SE, Shippy RA, Cantor MH. Older Adults with HIV: An In-depth Examination of an Emergency Population. New York, NY: Nova Science; 2009. [7] Fredriksen-Goldsen KI, Emlet CA, Kim H-J, et al. The physical and mental health of lesbian, gay male and bisexual (LGB) older adults: the role of key health indicators and risk and protective factors. Gerontologist. 2013;53:664–675. [8] Hampton MC, Halkitis PN, Mattis JS. Coping, drug use, and religiosity/spirituality in relation to HIV serostatus among gay and bisexual men. AIDS Educ Prev. 2010; 22:417–429. [9] Halkitis PN, Kupprat SA, Hampton MB et al. Evidence for a syndemic in aging HIV-positive, gay, bisexual, and other MSM: implications for a holistic approach to prevention and health care. Annals Anthro Pract. 2013; 36; 265–386. [10] Grov C, Sarit G, Parsons JT, et al. Loneliness and HIV-related stigma explain depression among older HIV positive adults. AIDS Care. 2010;22:630–639. [11] Emlet CA, Brennan DJ, Brennanstuhl S, et al. Protective and risk factors associated with stigma in a population of older adults living with HIV in Ontario, Canada. AIDS Care. 2013;1330–1339. [12] Emlet CA, Fredriksen-Goldsen KI, Kim H-J. Risk and protective factors associated with health-related quality of life among older gay and bisexual men living with HIV disease. Gerontologist. 2013;53:963–972. [13] Emlet CA. “You’re awfully old to have this disease": experiences of stigma and ageism in adults 50 years and older living with HIV/ AIDS. Gerontologist; 2006;46;781–790. [14] Crepaz NC, Marks GM. Are negative affective states associated with HIV sexual risk behaviors? a meta-analytic review. Health Psychol. 2001;20:291–299.
[15] Halkitis PN, Perez-Figueroa RE, Carreiro T, et al. Psychosocial burdens negatively impact HIV antiretroviral adherence in gay, bisexual and other men who have sex with men age 50 and over. AIDS Care. 2014; Epub ahead of print. [16] Centers for Disease Control and Prevention. HIV disease among Hispanics/Latinos in the United States and dependent areas. 2013. Retrieved from http://www.cdc.gov/hiv/pdf/risk_latino.pdf. [17] Hillman J. Sexuality and Aging. New York, NY: Springer; 2012. [18] Durvasula RS. Progress report: Psychopathology, decision making and sexual risk. 2013. [19] Murphy DA, Roberts KJ, Herbeck DM. HIV-positive mothers with late adolescent/early adult children: “empty nest” concerns. Health Care Women Int. 2012;33:387–402. [20] Diverse Elders Coalition. Eight Policy Recommendations for Improving the Health and Wellness of Older Adults with HIV. Issue Brief. New York, NY: Diverse Elders Coalition; 2014. http://www. diverseelders.org/what-to-know/hiv-aging. [21] Vance DE, Struzick TC, Masten J. Hardiness, successful aging, and HIV: implications for social work. J Gerontol Soc Work. 2008;51:260–283. [22] Emlet CA, Tozay S, Raveis V. “I’m not going to die from the AIDS”: resilience in aging with HIV disease. Gerontologist. 2011;51:101– 111. [23] Emlet CA, Brennan DJ, Furlotte C, Pierpaoli. Understanding the lived experiences of older adults living with HIV in Ontario: an examination of strengths and resilience in a vulnerable population. Can J Inf Dis Micro. 2014;25:221 (abstract). [24] Halkitis PN. The AIDS Generation: Stories of Survival and Resilience. New York: Oxford; 2014.
Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
Current Knowledge and Future Directions on Aging and HIV Research Charles A. Emlet
a
a
University of Washington Tacoma Published online: 04 Aug 2014.
Click for updates To cite this article: Charles A. Emlet (2014) Current Knowledge and Future Directions on Aging and HIV Research, Behavioral Medicine, 40:3, 143-148, DOI: 10.1080/08964289.2014.935235 To link to this article: http://dx.doi.org/10.1080/08964289.2014.935235
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
BEHAVIORAL MEDICINE, 40: 143–148, 2014 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print/1940-4026 online DOI: 10.1080/08964289.2014.935235
CONCLUSION
Current Knowledge and Future Directions on Aging and HIV Research Downloaded by [Flinders University of South Australia] at 14:47 07 February 2015
Charles A. Emlet University of Washington Tacoma
In 2012, the National Institutes of Health (NIH) Office of AIDS Research, through the HIV and Aging Working Group developed a document entitled HIV and Aging: State Of Knowledge and Areas of Critical Need For Research.1 The goal of the report was to “assess what is known and unknown and what the priorities should be for research at the interface of HIV, aging, and multimorbidity.”(pS2) The importance of this agenda is underscored by the often cited figure that by the year 2015, half of all people living with HIV in the US will be age 50 or over.1 More recently, another projection suggests that by 2020 approximately 70% of those living with HIV disease in the United States will be over the age of 502—a sobering statistic. The research priorities articulated in the Working Group report, along with the articles in this issue of Behavioral Medicine, help point the way for the current pulse, as well as future directions of aging and HIV research. The articles contained in this issue represent a slice of the diversity of research, thematically and methodologically, that is being conducted in the area of aging and HIV at this point in time. The six articles contained herein cover several important areas of inquiry, including: substance use (including tobacco and illicit drugs), teletherapy related to depression treatment and the lowering of sexual risk behavior, and two articles that recognize the diversity and heterogeneity of this population including older women and older Latino/as. The purpose of this article is to briefly summarize the six research studies contained in this issue of Behavioral Medicine and provide some thoughts and suggestions for future research.
Correspondence should be addressed to Charles A. Emlet, PhD, MSW, University of Washington Tacoma, 1900 Commerce St., Campus Box 358425, Tacoma, WA 98402-5825, USA. E-mail: [email protected]. edu
OLDER ADULTS LIVING WITH HIV AND SUBSTANCE USE As discussed in the report by the Working Group,1 substance use has played a critical role in HIV through both direct transmission behaviors (injection drug use) and secondary transmission whereby substance use increases risk behaviors associated with HIV infection. Older adults living with HIV are more likely than their HIV negative counterparts to continue substance abuse including tobacco, alcohol, opioids, and other substances.3 Numerous studies have found that individuals of all ages who are HIV-positive are more likely to use tobacco.4 For example, Fredriksen-Goldsen and colleagues,5 in a study of 2,650 lesbian, gay, bisexual, and transgender older adults found those with HIV were significantly more likely to smoke tobacco than their HIV negative counterparts. Due to the high risk of smoking behavior among older adults living with HIV, it is critical we better understand the impact of tobacco on comorbidities, and treatment outcomes as suggested by the NIH panel.1 Ompad and colleagues report on the relationship between smoking among older HIV-positive adults and various health outcomes. The health outcomes in this study were specific to factors associated with HIV disease including medication adherence and rates of opportunistic infections (OIs). This study, focusing specifically on a sample of older gay and bisexual men, as well as other men who have sex with men (N D 199), found that 70% were current or former smokers. Smoking was associated with other behaviors that may impact health such as a higher likelihood of illicit drug use. Additionally, older adults living with HIV who currently smoke were found to have characteristics associated with poorer health outcomes and clinical markers specifically related to HIV management. For example, smokers were significantly less likely to report
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an undetectable viral load than either former smokers or nonsmokers, and were more likely to have CD4 cell counts less than 500 cell/ml. The researchers of this study also found smoking to be related to negative impacts on other HIV related health outcomes. Smoking was significantly associated having been diagnosed with an OI at some point in time, while current and former smokers were more likely than nonsmokers to have reported a respiratory OI in their lifetime. Smokers were more likely to have candidiasis and PCP, and were significantly more likely to report a gastrointestinal OI. We know smoking has a negative impact on all people, but the results of this study suggest the impact may be more severe for HIV-positive individuals, particularly in regard to HIV-related health outcomes. Smoking clearly needs to be considered as part of any array of substance-use assessments, and the importance of cessations programs for HIVpositive individuals should be carefully considered as part of primary or secondary prevention activities. The research by Brennan-Ing, Porter, Seidel, and Karpiak presented in this issue extends the focus on substance use and its impact on older adults living with HIV disease. These researchers used data from the ROAH (Research on Older Adults with HIV) study6 to examine the role of substance use and sexual risk behavior among 239 older gay and bisexual men. This article sets an important stage, first by acknowledging the heterogeneity that exists within older adults living with HIV; recognizing, in this instance, potentially important differences between gay and bisexual men. As more data on LGBT older adults becomes available through scientific studies7 we can better understand important differences between subgroups of sexual minorities. As previously mentioned, substance use can result in an increase is sexual risk behavior,1 and this study sought to enlighten our understanding of differences in substance use between older gay and bisexual older men (living with HIV) and whether substance use is associated with unprotected intercourse. There is clear evidence that substance use patterns differ between HIV-positive individuals and their HIV negative peers.5,8 What is perhaps less clear, are differing patterns of substance use among HIV-positive gay versus bisexual men (these two populations are often merged in HIV research). The results of this study confirm significant and substantial differences between these two groups. For example, the researchers found bisexual men were more likely to be current smokers, and were more likely to endorse using tobacco, cocaine, crack cocaine and heroin than their gay counterparts. Gay men in this sample, however, were significantly more likely to use crystal meth, club drugs, poppers, and erectile dysfunction medications. With regard to sexual risk behavior, sexual orientation was not significant in the final regression analysis, however current use of ED medications and use of poppers resulted in increased odds of unprotected sex.
This study brings to light important differences between older gay and bisexual men. The study noted a number of differences in substance use patterns between these two groups, differentiated by the types of drugs in question. Recent research has, for example, documented important differences between older gay and bisexual men including higher risk for cardiovascular disease, stress, and loneliness among bisexual men.5 As the authors of this study suggest, recognizing differences between older gay and bisexual men is critical to sound assessment of risk as well as service provision, and it is important that providers do not make assumptions about similarities between these populations based on the sex of their sexual partners. Brennan-Ing and colleagues go on to reinforce the importance of recognizing group differences in conducting research. It is common, for example, for researcher to collapse these two groups due to small sample sizes. While such an approach can be methodologically necessary, the limitation of not differentiating between gay and bisexual men must be recognized as a limitation. At the same time, researchers need to consider syndemic theory, the overlapping and reinforcing of health problems9 in the older adults. Recently, Halkitis and colleagues9 have applied syndemic theory to a population of older HIV-positive gay, bisexual, and other MSM reinforcing the complexity of substance use and other areas of health. MENTAL HEALTH AND ASSOCIATED PSYCHOSOCIAL ISSUES The rapidly expanding literature on aging and HIV (see the introduction in this issue) has documented the variety of mental health and psychosocial issues impacting this population. Many of these mental health and psychosocial issues are highly interrelated. For example, social isolation and loneliness are associated with depression1 and stigma10 among older HIV-positive adults. Lower levels of social support have been associated with increased HIV stigma11 and lessened mental health quality of life among older, HIV-positive gay and bisexual men.12 Additionally, older adults face layering from HIV stigma, ageism, and other characteristics that may be stigmatized by society such as racial and ethnic background or HIV-risk behaviors.13 As pointed out by the HIV and Aging Working Group,1 research in this area must work toward enhancing our understanding of the sociobehavioral influences that impact aging and HIV in order to improve positive outcomes. The NIH report points out a clear objective that studies focusing on the mental health needs of this population and potential interventions need to be encouraged. Two articles contained in this issue do exactly that. They seek to improve our understanding of treatment approaches to mental health issues in this population through randomized control trials (RCT).
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The first RCT study conducted by Heckman and colleagues sought to determine the acceptability and efficacies of two types of teletherapy treatments for depression among groups of older MSM and heterosexuals living with HIV disease. For this study, 361 older adults were recruited from 24 states. A score of 10 or greater on the Geriatric Depression Scale (30-item version) was required for participation. Groups based on sexual orientation were assigned to telephone coping effectiveness training, telephone supportive-expressive group therapy, or a standards of care control. The study sought to assess the impact of these teletherapy formats on depressive symptoms among the two differing populations of older HIV-positive adults. The researchers point out that teletherapy may be particularly efficacious for delivering therapy in light of potential privacy concerns associated with experiences of stigma and discrimination. With regard to the session attendance, MSM attended slightly more session in both categories of the treatment arm than their heterosexual counterparts, however differences were not statistically significant. This study found important differences in the efficacy of treatment for depression based on sexual orientation. In the MSM group, significantly fewer depressive symptoms were reported in the supportive, expressive group therapy post intervention compared to the standards of care group. The same pattern is true for heterosexuals in the same treatment condition, however in the heterosexual group, those lowered depressive symptoms were maintained at 4month and 8-month follow up intervals (not so for the MSM group). This research points to important concerns about the mental health needs and treatment of depression among older adults living with HIV disease. While supportive expressive group therapy was effective in reducing depressive symptoms, improved treatment outcomes were more likely to dissipate among the MSM group over time. These differences existed despite the fact that those in the MSM groups attended slightly more sessions of both treatment arms than their heterosexual counterparts. The findings from this study have two important take-away messages. First, that in an RCT, supportive expressive therapy is effective in reducing depressive symptoms in the populations studied. Second, the results again highlight the diversity and heterogeneity that exists within the population of older adults living with HIV disease and potentially the effectiveness of treatment over time. Lovejoy and colleagues examined the impact of depression on treatment efficacy related to secondary prevention designed to reduce sexual risk behavior. There is clear evidence establishing links between depression with sexual risk behaviors in HIV-positive persons.13 Researchers recruited a total of 100 individuals, age 45 or older, from five metropolitan areas of the Eastern and Midwestern
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United States. Individuals were assigned to a 4-session telephone motivational interviewing (“tele-MI”) condition, a 1session tele-MI condition using the same approach, or standards of care. Study results reinforce that midlife and older adults living with HIV not only continue to be sexually active, but engage in sexual risk behavior. Half (49%) reported engaging in non-condom protected sex with HIV-positive persons in the previous three months and 59% reported sexual relationships with one or more casual/anonymous sexual partners in the previous three months. Regarding the impact of depression on sexual risk behavior, respondents with lower depressive symptoms had the highest level of non-condomprotected anal and vaginal sex acts (10.6) compared to those with higher depression (4.7) or no depressive symptoms (7.3). When the efficacy of the 4-session tele-MI was examined by depression levels, important and interesting patterns emerged. For example, those with no depressive symptoms had fewer episodes of non-condom-protected sex compared to the other two treatment arms. What is also important to consider, however, is that those differences were not sustained at the 6-month follow up. Those individuals with low levels of depressive symptoms (and the highest rate of non-condom-protected sex) at baseline, had a greater decrease in the target behaviors at both 3and 6-month follow ups. Those with high depressive symptoms did not differ from other participants at 3- or 6month follow up. Mental health issues, particularly depression, can seriously impact the lives of older persons living with HIV in a myriad ways. The two studies just discussed identified depression and other characteristics as important factors to consider. In the first study, we learned of the impact sexual orientation may have not only in willingness to be involved in treatment, but treatment efficacy. Second depression based on levels of symptomatology, can impact the efficacy of secondary prevention strategies for reducing non-condom protected sex among midlife and older adults. Recently, Halkitis and colleagues found depression to be associated with poorer antiretroviral therapy adherence in a sample of 180 HIV-positive MSM in New York City.15 The mental health studies in this issue, along with other recent research, reinforce the impact depression and other mental health issues can have on older HIV-positive adults. Treatment adherence and efficacy of secondary prevention strategies can be impacted by depressive symptoms. We also know from the research published in this issue, that the efficacy of treatment for depression may be impacted by sexual orientation. How gender, sexual orientation, and other psychosocial factors impact depression treatment and how depressive symptoms can impact HIV adherence and psychosocial stability are all areas needing to be unraveled in future research.
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AT-RISK POPULATIONS WITHIN HIV-POSITIVE OLDER ADULTS Older adults living with HIV are a diverse and heterogeneous group. People living with HIV represent gender and racial minorities who are continually confronted by social and economic constraints.1 Recognizing the diversity within the older adult population, it is important to construct an aggressive research agenda that will enlighten not only what we know about different groups, but how we come to understand this information. Two groups of older adults who receive minimal research consideration are women and Latino/as. The older Hispanic population is disproportionally impacted by HIV disease.16 Older women are also at increased risk for HIV infection due to physiologic changes and social stigma and views on sexuality.17 Durvasula provides an important scholarly overview of issues facing older women living with HIV disease. The authors point out that little research has focused specifically on older women living with HIV despite the fact that they must contend with differing physical, psychological and psychosocial burdens. Older women living with HIV are often invisible due to myths about aging, sexuality, and risk. Unfortunately, both older women themselves as well as service providers lack understanding, thus contributing to a lack of testing and treatment. For example, younger providers may feel embarrassment talking with older women about sexuality or sexual risk and carry ageist beliefs about sexuality and older women. Due to this lowered perception of risk or insufficient screening, less testing can result in delayed diagnosis and treatment. Older women are more likely to not be in a committed relationship compared to their younger counterpart and the dynamics of negotiating safe sexual relationships can add to risk. Additionally, older women face issue of interpersonal violence, which contributes to HIV risk due to multiple partners, STI risk, and greater risk behavior among their partners. Too often, the resulting consequences of these risks include isolation, which creates its own set of mental health and psychosocial problems as discussed earlier. Durvasula points to the importance of physical care that is specific to older women; specifically, the interplay between HIV and menopause is of concern and further research in this area is needed. Additionally, the side effects of cART and that HIV symptoms can mimic age related comorbidities that can be more pronounced in older women. Older women also face a variety of neuropsychiatric issue that compound HIV. One study18 found 67% of older women reported an Axis I diagnosis compared to 50% of younger women. In addition, multiple threats to cognitive function may exist; including HIV, substance abuse, and age associated cognitive decline. In addition to the psychological, social, and physical elements of HIV in older women, the authors point out the importance of narratives in the lives of these older women
and in particular stories of coping and resilience. At the beginning of the article, the author introduces Yolanda, a 50 year old woman living with HIV since 1989. Through transition and growth HIV has “given her life meaning and community.” Murphy and colleagues19 have documented the hopes of HIV-positive women including change in life focus, self-improvement, romantic partners, and developing and healing family ties. In addition to the need for clinical trials and rigorous quantitative research, we also need to build on narrative approaches that may focus on resilience and move away from deficit based models building on the multiple strengths that exist in this population. The final article herein again focuses on the heterogeneity of the population of older adults living with HIV; specifically older Latina/o adults. According to the CDC, infection rates among Hispanics/Latinos in 2010 in the United States was more than 3 times as high as that of whites.16 Researchers and policymakers are being called on to better address the needs of older LGBT adults and older people of color living with HIV.20 People of all ages, particularly older adults, living with HIV are at risk for cognitive impairment including HIV associated neurocognitive disorders (HAND) and HIV associated dementia. In this study, Rivera Mindt and colleagues utilized a sample of 126 older and younger Latinas/os and Non-Hispantic Whites (NHW) to determine if Latinas/os are at risk for worsened neurocognitive outcomes than their NHW counterparts within the context of HIV and aging. The 126 participants (84 Latina/o and 42 NHW adult were recruited for a parent study in the Spanish Harlem neighborhood of New York City and ranged in age from 18–80. Those under 50 (n D 82) were considered younger while those over 50 (n D 44) were considered older. The results from the study suggest important differences and risk associated both with racial and ethnic background and age. For example, they found both older and younger Latino/as were more likely to have an AIDS diagnosis and more likely to have a detectable viral load as compared to the NHW counterparts. These findings raise concern for the potential of later diagnosis, poorer efficacy with medications or other contributing factors. When comparing the older age group only, Latino/as demonstrated mild impairment in learning and mild to moderate impairment of memory. No such impairments were found in the NHW group. The findings from this study suggest that even after controlling for relevant covariates, Latina/o ethnicity may put one at higher risk for HAND. We know from other research that US Latina/os suffer from health disparities outside of HIV. Whether these processes are linked needs further investigation. MOVING FORWARD The six articles included in this issue of Behavioral Medicine reflect the diverse populations of older adults impacted
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by HIV disease and the wide range of issues that confront people living with HIV, service providers and researchers. These studies address many of the areas needing further research outlined by the HIV and Aging Working Group. As the population of older adults living with HIV disease grows, the opportunity exists to conduct research, both quantitative and qualitative with more diverse populations and using larger sample sizes that are more geographically diverse. It is important to consider that individuals within this population exist within multiple and complex identities including sexual orientation and gender identity, racial and ethnic background, HIV cohort,24 socioeconomic status, rural versus urban residence, and many other factors that shape their experience and relationship with HIV. One area outlined by the working group that deserves specific mention is that of successful aging with HIV. It is important to encourage and foster research that emphasizes positive psychology, mindfulness, hardiness, and resilience, and to translate those findings to help those not successfully aging with HIV.1 While there is a growing body of research in the areas of successful aging and in resilience in people living with HIV, a combined focus is needed. Vance and colleagues21 has done important work in the area of hardiness, and recent research has focused on strengths and resilience in older HIV-positive adults.22 Recently, Emlet and colleagues conduced 30 in-depth interviews with older adults living with HIV in Ontario, Canada, focusing on successful aging. Many of the emerging themes from that research show strong relationships to the areas suggested by the HIV and Aging Working Group including the importance of mindfulness, spirituality, mastery, and resilience.23 In his groundbreaking book The AIDS Generation, Halkitis communicates the importance of resilience in the lives of midlife and older MSM who have been living with HIV for many years.24 Future research needs to begin to deepen our understanding of successful aging with HIV and how theoretical models for successful aging from the gerontological literature can be adapted to this specific population. Are characteristics associated with successful aging with HIV innate or learned? Are those traits or characteristics teachable? Can they be learned through intervention research? Future research can begin to move our embryotic understanding of this phenomenon to a more refined position whereby interventions can be developed and tested to improve individual responses to aging with HIV. As already mentioned, the increasing number of older adults living with HIV disease will expand our opportunity to conduct rigorous research with larger sample sizes and robust methodologies. Durvasula also points to the importance of understanding their lives through narratives. Some populations (as she suggests older women) are more amenable to engaging in research that focuses on the person’s individual lived experience. While we have learned a tremendous amount in the past few years, and the numbers of published research studies has grown dramatically, there is
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still a place for qualitative, narrative analysis capturing the lived experiences of this diverse population. A recent policy statement from the Diverse Elders Coalition19 also helps suggest future directions in aging and HIV research. The policy recommendations maintain that older adults living with HIV continue to be a profoundly understudied population in biomedical, clinical, and social science disciplines, and that the NIH should be appropriately funded to support this important research agenda. The Coalition also suggests that the NIH support funding priorities outlined in the HIV and Aging Working Group document, including but not limited to behavioral health and supportive resources. Consistent with the articles in this issue, that policy recommendation specifically identifies research funding to improve our understanding of HIV among older women, LGBT older adults, and communities of color.19 In addition to biomedical and social science research, the community of researchers and advocates needs to move this agenda into the policy arena, including the upcoming White House Conference on Aging and programming from the Older American’s Act. These improvements in aging policy will pave the way for research to address the tailoring and acceptability of services aimed at older adults living with HIV disease. This special issue of Behavioral Medicine significantly contributes to furthering and informing research on aging and HIV. The wide spectrum of research needed within this heterogeneous population was underscored by the variety of studies contained in this issue. As we move into the next decade and beyond, HIV and aging research will both be challenged by the overwhelming complexity of the topic and be motivated to contribute to this landscape of knowledge which changes constantly.
REFERENCES [1] High KP, Brennan-Ing M, Clifford DB, et al. HIV and aging: state of knowledge and areas of clinical need for research. A report to the NIH office of AIDS Research by the HIV and Aging Working Group. JAIDS. 2012;60: S1–S18. [2] Senate Special Committee on Aging. Testimony of Daniel Tietz. Older Americans: The changing face of HIV/AIDS in America. Report of the Senate Special Committee on Aging, 113th Congress; 2013. [3] Green TC, Kershaw T, Lin H, et al. Patterns of drug use and abuse among aging adults with and without HIV: a latent class analysis of a US veteran cohort. Drug Alcohol Depend. 2010;110:208–220. [4] Shuter J, Bernstein SL. Cigarette smoking is an independent predictor of nonadherence in HIV-infected individuals receiving highly active antiretroviral therapy. Nicotine Tob Res. 2008;10:731–736. [5] Fredriksen-Goldsen KI, Kim H-J, Emlet CA, et al. The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle, WA: Institute for Multigenerational Health. 2011. Retrieved from http://depts.washington.edu/ agepride/wordpress/wpcontent/uploads/2011/05/Full-Report-FINAL. pdf
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[6] Brennan M, Karpiak SE, Shippy RA, Cantor MH. Older Adults with HIV: An In-depth Examination of an Emergency Population. New York, NY: Nova Science; 2009. [7] Fredriksen-Goldsen KI, Emlet CA, Kim H-J, et al. The physical and mental health of lesbian, gay male and bisexual (LGB) older adults: the role of key health indicators and risk and protective factors. Gerontologist. 2013;53:664–675. [8] Hampton MC, Halkitis PN, Mattis JS. Coping, drug use, and religiosity/spirituality in relation to HIV serostatus among gay and bisexual men. AIDS Educ Prev. 2010; 22:417–429. [9] Halkitis PN, Kupprat SA, Hampton MB et al. Evidence for a syndemic in aging HIV-positive, gay, bisexual, and other MSM: implications for a holistic approach to prevention and health care. Annals Anthro Pract. 2013; 36; 265–386. [10] Grov C, Sarit G, Parsons JT, et al. Loneliness and HIV-related stigma explain depression among older HIV positive adults. AIDS Care. 2010;22:630–639. [11] Emlet CA, Brennan DJ, Brennanstuhl S, et al. Protective and risk factors associated with stigma in a population of older adults living with HIV in Ontario, Canada. AIDS Care. 2013;1330–1339. [12] Emlet CA, Fredriksen-Goldsen KI, Kim H-J. Risk and protective factors associated with health-related quality of life among older gay and bisexual men living with HIV disease. Gerontologist. 2013;53:963–972. [13] Emlet CA. “You’re awfully old to have this disease": experiences of stigma and ageism in adults 50 years and older living with HIV/ AIDS. Gerontologist; 2006;46;781–790. [14] Crepaz NC, Marks GM. Are negative affective states associated with HIV sexual risk behaviors? a meta-analytic review. Health Psychol. 2001;20:291–299.
[15] Halkitis PN, Perez-Figueroa RE, Carreiro T, et al. Psychosocial burdens negatively impact HIV antiretroviral adherence in gay, bisexual and other men who have sex with men age 50 and over. AIDS Care. 2014; Epub ahead of print. [16] Centers for Disease Control and Prevention. HIV disease among Hispanics/Latinos in the United States and dependent areas. 2013. Retrieved from http://www.cdc.gov/hiv/pdf/risk_latino.pdf. [17] Hillman J. Sexuality and Aging. New York, NY: Springer; 2012. [18] Durvasula RS. Progress report: Psychopathology, decision making and sexual risk. 2013. [19] Murphy DA, Roberts KJ, Herbeck DM. HIV-positive mothers with late adolescent/early adult children: “empty nest” concerns. Health Care Women Int. 2012;33:387–402. [20] Diverse Elders Coalition. Eight Policy Recommendations for Improving the Health and Wellness of Older Adults with HIV. Issue Brief. New York, NY: Diverse Elders Coalition; 2014. http://www. diverseelders.org/what-to-know/hiv-aging. [21] Vance DE, Struzick TC, Masten J. Hardiness, successful aging, and HIV: implications for social work. J Gerontol Soc Work. 2008;51:260–283. [22] Emlet CA, Tozay S, Raveis V. “I’m not going to die from the AIDS”: resilience in aging with HIV disease. Gerontologist. 2011;51:101– 111. [23] Emlet CA, Brennan DJ, Furlotte C, Pierpaoli. Understanding the lived experiences of older adults living with HIV in Ontario: an examination of strengths and resilience in a vulnerable population. Can J Inf Dis Micro. 2014;25:221 (abstract). [24] Halkitis PN. The AIDS Generation: Stories of Survival and Resilience. New York: Oxford; 2014.
