CARE OF THE OLDER PERSON
The health-care needs of the older gay man living with HIV Ian Peate
Ian Peate is an Independent Consultant
AbstracT
Human immunodeficiency virus (HIV) was once thought of as a condition predominately affecting the young. However, HIV among the older population is increasing. Older gay male adults living with HIV have received little attention from those who provide and commission services. However, with effective treatment, those gay men aged over 50 are the fastest growing group of people with HIV in the UK. Nurses will be required to offer care in a number of ways to this cohort of patients. In so doing, nurses will need to develop innovative and effective ways of supporting this growing group of people. This article provides an overview of the issues that can impact on the health and wellbeing of the older gay man living with HIV. The article discusses the epidemiology, the issue of HIV stigma, comorbidities and mental health and wellbeing needs.
KEY WORDS Long-term condition w Support w Stigma w Ageing
492
Epidemiology In the UK at the end of 2011 there was an estimated 96 000 (90 800–102 500) people living with HIV, this represents an increase from 91 500 (85 400–99 000) in 2010. In 2011 the overall prevalence was 1.5 per 1000 people, with the highest rates being reported among men who have sex with men (MSM) (47 per 1000) and the black African community (37 per 1000) (Health Protection Agency (HPA), 2012). The number of people over the age of 50 in the UK living with HIV has increased. There has also been a shift in the age distribution: in 2011, one in five adults (22%; 16 550) accessing HIV care were aged 50 and over, compared with one in nine (12%; 3640) in 2002 (HPA, 2012). Currently, MSM are the largest group of older people infected with HIV accessing care in the UK. The emergence of this ageing group and the reduction in the HIV mortality rate is attributed to the introduction of HAART (Lyons et al, 2010). Community nurses will meet and treat more older gay men living with HIV in the future.
HIV and stigma Goffman (1963) defined stigma as attributes that are deeply discrediting. HIV stigma greatly affects quality of life for older gay men with HIV. Stigma has the potential to damage and destroy a person’s sense of self-worth and identity. It is important for nurses to understand the impact of stigma on behaviours and self-perceptions of people living with HIV/AIDS because those who are stigmatised are less likely to display health-seeking behaviours. The quality of life of older gay men living with HIV can be adversely affected when they experience stigma associated with HIV. People living with HIV often internalise stigma in feelings of shame, guilt, anger, fear and self-loathing (Emlet, 2006) and many of them can experience social avoidance, the real or apparent loss of friends and a feeling that people are uncomfortable being around them as a result of their HIV disease. Vanable et al (2006) suggest that those who experience HIV-related stigma are more likely to suffer depressive symptoms, to report receiving recent psychiatric care and to report greater HIV-related symptomatology. Feelings of internalised HIV stigma can contribute to depression, anxiety and hopelessness. Stigma and internalised homophobia can negatively affect resilience. Public opinion about AIDS is clearly correlated with perceptions and attitudes toward homosexuality and sexual orientation, and is fundamental to the discussion of HIV
© 2013 MA Healthcare Ltd
T
he number of human immunodeficiency virus (HIV) positive adults living into older age (typically defined as 50 years and older) has been steadily increasing in western countries since the introduction in 1995 of highly active anti-retroviral therapy (HAART) (antiretroviral therapy (ARV). As people are living with HIV into old age they will need increasing social and clinical support from health-care providers, including community nurses. With complex health problems, scarcer financial resources and greater isolation than many of their peers, older people living with HIV face major challenges (Power et al, 2010). Gay men are more severely affected by HIV than any other group in the UK. What was once an infection that would certainly lead to death is becoming a more chronic, manageable condition and this is good news. It must be remembered that the treatment that is currently available is not a cure, and older gay men living with HIV have to cope with living with HIV for the rest of their lives. The clinical understanding of HIV as well as its long-term management continues to develop. However, nurses must be aware that those living with the virus will be living with very high levels of uncertainty about their future health. The health and social care needs around older people living with HIV and acquired immunodeficiency syndrome (AIDS) in the UK has not been addressed before. It is already well known that health and social care systems are struggling to cope with the current demand made by society and as older gay men live longer with HIV the systems will be further challenged.
Email: [email protected]
British Journal of Community Nursing Vol 18, No 10
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CARE OF THE OLDER PERSON stigma. As a result of this, older gay men with HIV will encounter discrimination, rejection, prejudice and stereotyping as a result of the stigma associated with their real or supposed sexual orientation. In a discussion on American and Canadian attitudes, Andersen and Fetner (2008) note that because older adults tend to hold more conservative views on issues of gay rights and homosexuality, older HIV-positive adults may in turn experience difficulty in their relations with age peers. As a result, they may internalise their own feelings of guilt or shame regarding their HIV. There is no reason to suppose that these attitudes would not be the same or similar in the UK. Older gay men with HIV often become disconnected from their friends, family and society at large, with many men reporting feeling separated, alone, isolated and rejected by their community and peers (Power et al, 2010). Social isolation and a lack of social networks and support leaves older gay men living with HIV vulnerable as they have less resources and are more susceptible to negative outcomes such as: w Depression w Bereavement w Poor mental health w Substance abuse.
© 2013 MA Healthcare Ltd
Support from nurses As a result of the situation that may face older gay men living with HIV, there is a need for nurses, working as members of the multidisciplinary team, to contribute to the development of innovative support networks and systems that will support this vulnerable and growing group of patients. In so doing, nurses can ensure that they make the care of the person they are caring for their first concern, treating them as individuals and respecting their dignity (Nursing and Midwifery Council, 2008). Internalised homophobia, denial of risk, alcohol and other substance use, and anonymous sexual encounters are all HIV risk factors for older gay men. The challenge for nurses and others who provide health and social care is to engage, educate and assist them effectively in changing and maintaining safe behaviour when engaging in sexual and drug-using activities that can transmit HIV. Older gay men over the age of 50 have been, and continue to be, an invisible part of the HIV/AIDS epidemic. The reasons for this are many, but among them are societal beliefs, myths, and stereotypes emanating from ageism and homophobia. In addition, HIV/AIDS is sometimes misdiagnosed in older adults because many of its symptoms mimic other illnesses that affect older people. For example, Pneumocysis (carinii) jiroveci pneumonia can often present with an insidious onset of breathlessness and malaise. This is not always accompanied by pyrexia. In older patients, symptoms can mimic cardiac disease in the early stages. Oropharyngeal candidiasis, which relapses after satisfactory treatment whether or not there are associated gastrointestinal symptoms should raise suspicion of an underlying immune paresis (Pratt et al, 2010).
British Journal of Community Nursing Vol 18, No 10
Comorbidities and other conditions Gebo (2006) has demonstrated that there are toxic effects associated with long-term exposure to ARVs. These include a reduction in both the number of years a person can expect to live and in the quality of life of the person exposed to ARVs. The impact on ageing with HIV is so new that there is very little known about it from a biomedical perspective, particularly in terms of the impact on the older person. ARVs interact in a complex way with body systems. Effros et al (2008) suggest that even when the immune system is stabilised by the use of ARV therapies, HIV has the ability to accelerate the effects of ageing, especially in relation to cognition. Older people with HIV have a higher proportion of comorbidities, which means that issues associated with drug and disease interactions may apply. The issue of HIV medications and their interaction with other medications must be given serious consideration by those nurses who care for older gay men with HIV. Current research in this area is limited and further research would be beneficial.
Side effects of ARV therapy There are a number of benefits associated with the use of ARV drugs. However, as with many types of medication, ARVs are not without their side effects, and as older people are less able to metabolise ARVs there is a possibility that increased toxicity will occur (Gebo, 2006). However, the long-term use of ARV therapy can bring with it other issues for the older adult, which can increase a person’s risk of several comorbidities. Bhavan et al (2008) demonstrated that there is an increased risk of heart attack associated with longer exposure to ARV therapies, and protease inhibitors in particular. Some possible side effects that can occur from taking ARVs are as follows: w Liver toxicity w Osteoporosis w Pancreatitis w Lipodystrophy w Peripheral neuropathy w Build-up of lactic acid. Another common problem that corresponds with the rise of effective HIV therapies is the emergence of obesity (Bhavan et al, 2008). Wand et al (2007) note that symptoms related to heart disease, including abdominal obesity, insulin resistance and hypertension increased from 8.5% to 26.5% in HIV positive individuals after commencing ARV therapy (Bhavan et al, 2008). HIV infection and HAART have also been associated with hyperlipidemia, which carries with it another risk factor for heart disease (Simone and Appelbaum, 2008). The fact that drug interactions can cause further health complications particularly affects older people with HIV who, as the result of an increased frequency of comorbidities within this population, are likely to be taking two or more medications for a number of other conditions concurrently. The combination of ARVs may result in abnormal bone metabolism, with longer-term therapy having a greater effect on bone density as opposed to erratic or irregular regimens (Kirk and Goetz, 2009).
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CARE OF THE OLDER PERSON
The immune system Ageing can have significant effects on a person’s immune system. Coupled with HIV, this can lead to severe challenges. HIV reduces a person’s T-cell count, and Kalayjian and Al-Harthi (2009) note that this leads to HIV-positive individuals having a T-cell population that is similar to that of someone 20–30 years older, reducing a person’s ability to defend the body against infection.Antibodies in the immune system are reduced due to ageing (Effros et al, 2008), leaving the older HIV-positive adult with an increased risk of potentially life-threatening infections (for example, pneumonia). Martin et al (2008) have demonstrated that the immune systems of HIV positive older adults receiving ARV therapy do not recover as quickly as those of the younger adult population. Baker et al (2008) note that there is a relationship between a lower CD4 count and an increased risk of heart, kidney and liver disease, and cancer.
Cancer Older adults with HIV have a generally elevated risk of cancer when compared with the general population (Grulich et al, 2007), with significantly higher incidence of several kinds of cancer: w Melanoma w Leukaemia w Hodgkin’s lymphoma w Colorectal w Renal w Anal w Liver w Lung w Mouth w Throat. Cranston et al (2007) discuss the issue of anal cancer, which is rare in the general population.The rate of incidence increases to up to 40 times for HIV-positive MSM.
LEARNING POINTS w Community nurses and other health and social care workers will be required to provide support to the growing number of older HIVpositive gay men w Older HIV-positive gay men often experience a triple stigma related to ageism, public misunderstandings about HIV/AIDS and anti-gay prejudice w Nurses have a duty to understand how issues of sexuality, the physical and mental impact of social isolation, stigma and comorbidity issues can have negative outcomes on the health and wellbeing of the older gay man living with HIV
494
Non-AIDS-related cancers (NARCs) (including anal, lung and liver cancer) have become more common among people with HIV than AIDS-related cancers such as Kaposi’s sarcoma and non-Hodgkin’s lymphoma (Engels et al, 2008). Deeks and Philips (2009) note that the relationship between NARCs and HIV is currently not well understood; immunodeficiency is associated with greater risk of their development. People infected with HIV do not have increased risk of breast, colorectal, prostate or many other common types of cancer (Grulich et al, 2007). Nurses should ensure that screening for these cancers in older people living with HIV should adhere to current guidelines that are in use for the general population.
Mental health In the UK, poor mental health is the largest cause of disability. It is also closely connected with other problems such as poor physical health, and problems in other areas of life, such as relationships, education and work prospects. The Department of Health (DH) strategy for mental health (DH, 2011) makes it clear that if improvements to people’s lives are to be made, then improvements to their mental health and wellbeing will be required. Older gay men living with HIV are confronted with stigma from multiple sources, which intensifies the negative impact on health and wellbeing. Furthermore, HIV and ageing can have significant effects on the brain. Older adults with HIV are, on average, more susceptible to negative mental health outcomes such as depression, dementia and Alzheimer’s disease. Cherner et al (2004) indicated that older people with demonstrable levels of HIV in their spinal fluid were twice as likely to have psychological impairment as those with no detectable virus. Ances et al (2010) note increased ageing of the brain among individuals with HIV, as well as lower-than-normal blood flow to the brain, matching levels usually seen in people 15–20 years older. Older HIV-positive adults are more likely to be diagnosed with depression compared with the general population (Gebo, 2006). It has also been demonstrated that older HIVpositive people have a greater prevalence of substance use, with the rate of depression having been shown to increase with age (Gebo, 2006). The impact of the medication used in HAART on a person’s mental health is currently unknown. Myers (2009) suggests that ARV therapy could cause damage that increases the risk of Alzheimer’s disease, which is not normally associated with HIV. At least one study suggests that the use of some ARV medications is associated with depression and other psychiatric side effects (Simone and Appelbaum, 2008). Power et al (2010) found that older gay people living with HIV are fearful that social care services, care homes and sheltered housing might be HIV-prejudiced or homophobic. While the majority of respondents in their study thought highly of their HIV clinicians, many reported poor experiences in primary care. Respondents in the study stated that their highest future priority was for good-quality health and treatment information.
© 2013 MA Healthcare Ltd
The interaction of ARVs and cholesterol medications for those people who are co-infected with HIV and hepatitis can cause liver toxicity. This is a serious concern as there is an association between low CD4 counts and an increased risk of death from liver disease (Gebo, 2006).
British Journal of Community Nursing Vol 18, No 10
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CARE OF THE OLDER PERSON The mental health needs of the older gay man living with HIV can often be overlooked by nurses and doctors who may focus their attention on the physical impact of HIV, in spite of the fact that depression can exacerbate immune system dysfunction (Karpiak and Shippy, 2006).
The role of the nurse The role of the nurse is to provide high-quality, safe and effective care to all.When caring for older gay men with HIV, care provision must be contextualised and related closely to the situation in which the nurse is asked to intervene. Mandatory training should be provided by employers that includes methods for providing good-quality care for older gay men with HIV that is sensitive to their needs. Nurses conducting assessments should be knowledgeable about the needs of older gay men with HIV so that these needs are taken into account during the assessment process. The nurse should ensure that older gay men with HIV have access to relevant advice concerning services, social groups and other resources. Nurses and other health-care staff should use open language when talking to patients to give older gay men with HIV confidence to be open about their sexual orientation. Confidentiality policies should be clear to all patients and make clear to older gay men whether or not they would like their sexual orientation to be included in their medical records. Nurses and other care workers who provide services to people in their home should never assume a patient’s sexual orientation. It is unacceptable for care and support staff to discuss their personal views about lesbian, gay and bisexual people or issues. In the residential care setting, care homes should apply the same polices and procedures to same-sex couples wanting to live together in care homes as heterosexual couples. Older same-sex couples should be allowed private time or be allowed to show affection for one another, as is the case for heterosexual couples. Clear policies on what is acceptable and unacceptable behaviour for residents should be developed.
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Conclusion Since the beginning of the epidemic over 30 years ago, HIV has been transformed from being a life-threatening disease to a chronic illness. Older HIV-positive adults can often experience a triple stigma related to ageism, public misconceptions about HIV/AIDS and anti-gay prejudice. As the number of HIV positive people aged 50 and older increases in the UK, appropriate measures must now be taken to ensure that the needs of this diverse population are met. Those who provide and commission care services must understand and make provision for the high incidence of comorbidities and the long-term effects of ARV therapies. The social context in which older gay men with HIV/ AIDS live, including the damaging effects of stigma on their physical health and emotional wellbeing, must also be given consideration as nurses strive to improve care. As most HIV research has generally focused on younger gay men, there is an urgent need for further research into this group of HIV-positive older men.
British Journal of Community Nursing Vol 18, No 10
It is imperative that health-care providers, nurses and those who commission services understand how the factors discussed in this article can affect the older HIV-positive gay man, including (but not restricted to) issues of sexuality, the physical and mental impact of social isolation, stigma and comorbidity issues. BJCN Acknowledgements: The author would like to thank Frances Cohen for her help and support. Ances BM, Vaida F, Yeh MJ (2010) HIV infection and aging independently affect brain function as measured by functional magnetic resonance imaging. J Inf Diseases 201(3): 336–40 Andersen R, Fetner T (2008) Cohort differences in tolerance of homosexuality: attitudinal change in Canada and the United States, 1981-2000. Pub Opinion Quarterly 72(2): 311–30 Baker JV, Peng G, Rapkin J et al (2008) CD4+ count and risk of non-AIDS diseases following initial treatment for HIV infection. AIDS 22(7): 841–8 Bhavan K, Kampalath V, Turner Overton E (2008) The aging of the HIV epidemic. Current HIV/AIDS Reports 5(3): 150–8 Cherner M, Ellis RJ, Lazzaretoo D et al (2004) Effects of HIV-1 infection and aging on neurobehavioral functioning: preliminary findings. AIDS 18 (Supp 1): S27–34 Cranston RD, Hart SD, Gornbein JA, Hirschowitz SL, Cortina G, Mow AA (2007) The prevalence, and predictive value, of abnormal anal cytology to diagnose anal dysplasia in a population of HIV-positive men who have sex with men. Int J STD AIDS 18(2): 77–80 Deeks SG, Phillips AN (2009) HIV infection, antiretroviral treatment, ageing, and non-AIDS related morbidity. BMJ 338: a3172 Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages. http://tinyurl.com/ p29gvps (accessed 30 August 2013) Effros RB, Fletcher CV, Gebo K et al (2008) Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis 47(4): 542–53 Emlet CA (2006) A comparison of HIV stigma and disclosure patterns between older and younger adults living with HIV/AIDS. AIDS Patient Care STDs 20(5): 350–8 Engels EA, Biggar RJ et al (2008) Cancer risk in people infected with human immunodeficiency virus in the United States. Int J Cancer 123(1): 187–194 Gebo KA (2006) HIV and aging: implications for patient management. Drugs Aging 23(11): 897–913 Goffman E (1963) Stigma: Notes on the Management of Spoiled Identity. Harmondsworth: Penguin Grulich AE, van Leeuwen MT, Falster MO,Vajdic CM (2007) Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 370(9581): 59–67 Health Protection Agency (2012) HIV in the United Kingdom: 2012 report. http:// tinyurl.com/q2cspfs (accessed 30 August 2013) Kalayjian RC, Al-Harthi L (2009) The effects of aging on HIV disease. In: Paul RH, Sacktor NC,Valcour V, Tashima KT, eds. HIV and the Brain: Current Clinical Neurology. Humana Press, New York Karpiak SE, Shippy RE (2006) Research on older adults with HIV. AIDS Community Research Initiative of America. http://tinyurl.com/npnmdcz (accessed 30 August 2013) Kirk J, Goetz M (2009) Human immunodeficiency virus in an aging population: a complication of success. J Am Geriatr Soc 57(11): 2129–38 Lyons A, Pitts M, Grierson J,Thorpe R, Power J (2010) Ageing with HIV: health and psychosocial well-being of older gay men. AIDS Care 22(10) 1236–44 Martin C, Fain M, Klotz C (2008) The older HIV-positive adult: a critical review of the medical literature. Am J Med 121(12): 1032–7 Myers JD (2009) Growing old with HIV: the AIDS epidemic and an aging population. JAAPA 22(1): 20–4 Nursing and Midwifery Council (2008) Code of Professional Conduct. http:// tinyurl.com/nrmbyvl (accessed 30 August 2013) Power L, Bell M, Freemantle I (2010) A national study of ageing and HIV (50 plus). Terence Higgins Trust. http://tinyurl.com/nvlj6dn (accessed 30 August 2013) Simone MJ, Appelbaum J (2008) HIV in older adults. Geriatrics 63(12): 6–12 Vanable PA, Carey MP, Blair DC, Littlewood RA (2006) Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behavior. 10(5): 473–82
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The health-care needs of the older gay man living with HIV Ian Peate
Ian Peate is an Independent Consultant
AbstracT
Human immunodeficiency virus (HIV) was once thought of as a condition predominately affecting the young. However, HIV among the older population is increasing. Older gay male adults living with HIV have received little attention from those who provide and commission services. However, with effective treatment, those gay men aged over 50 are the fastest growing group of people with HIV in the UK. Nurses will be required to offer care in a number of ways to this cohort of patients. In so doing, nurses will need to develop innovative and effective ways of supporting this growing group of people. This article provides an overview of the issues that can impact on the health and wellbeing of the older gay man living with HIV. The article discusses the epidemiology, the issue of HIV stigma, comorbidities and mental health and wellbeing needs.
KEY WORDS Long-term condition w Support w Stigma w Ageing
492
Epidemiology In the UK at the end of 2011 there was an estimated 96 000 (90 800–102 500) people living with HIV, this represents an increase from 91 500 (85 400–99 000) in 2010. In 2011 the overall prevalence was 1.5 per 1000 people, with the highest rates being reported among men who have sex with men (MSM) (47 per 1000) and the black African community (37 per 1000) (Health Protection Agency (HPA), 2012). The number of people over the age of 50 in the UK living with HIV has increased. There has also been a shift in the age distribution: in 2011, one in five adults (22%; 16 550) accessing HIV care were aged 50 and over, compared with one in nine (12%; 3640) in 2002 (HPA, 2012). Currently, MSM are the largest group of older people infected with HIV accessing care in the UK. The emergence of this ageing group and the reduction in the HIV mortality rate is attributed to the introduction of HAART (Lyons et al, 2010). Community nurses will meet and treat more older gay men living with HIV in the future.
HIV and stigma Goffman (1963) defined stigma as attributes that are deeply discrediting. HIV stigma greatly affects quality of life for older gay men with HIV. Stigma has the potential to damage and destroy a person’s sense of self-worth and identity. It is important for nurses to understand the impact of stigma on behaviours and self-perceptions of people living with HIV/AIDS because those who are stigmatised are less likely to display health-seeking behaviours. The quality of life of older gay men living with HIV can be adversely affected when they experience stigma associated with HIV. People living with HIV often internalise stigma in feelings of shame, guilt, anger, fear and self-loathing (Emlet, 2006) and many of them can experience social avoidance, the real or apparent loss of friends and a feeling that people are uncomfortable being around them as a result of their HIV disease. Vanable et al (2006) suggest that those who experience HIV-related stigma are more likely to suffer depressive symptoms, to report receiving recent psychiatric care and to report greater HIV-related symptomatology. Feelings of internalised HIV stigma can contribute to depression, anxiety and hopelessness. Stigma and internalised homophobia can negatively affect resilience. Public opinion about AIDS is clearly correlated with perceptions and attitudes toward homosexuality and sexual orientation, and is fundamental to the discussion of HIV
© 2013 MA Healthcare Ltd
T
he number of human immunodeficiency virus (HIV) positive adults living into older age (typically defined as 50 years and older) has been steadily increasing in western countries since the introduction in 1995 of highly active anti-retroviral therapy (HAART) (antiretroviral therapy (ARV). As people are living with HIV into old age they will need increasing social and clinical support from health-care providers, including community nurses. With complex health problems, scarcer financial resources and greater isolation than many of their peers, older people living with HIV face major challenges (Power et al, 2010). Gay men are more severely affected by HIV than any other group in the UK. What was once an infection that would certainly lead to death is becoming a more chronic, manageable condition and this is good news. It must be remembered that the treatment that is currently available is not a cure, and older gay men living with HIV have to cope with living with HIV for the rest of their lives. The clinical understanding of HIV as well as its long-term management continues to develop. However, nurses must be aware that those living with the virus will be living with very high levels of uncertainty about their future health. The health and social care needs around older people living with HIV and acquired immunodeficiency syndrome (AIDS) in the UK has not been addressed before. It is already well known that health and social care systems are struggling to cope with the current demand made by society and as older gay men live longer with HIV the systems will be further challenged.
Email: [email protected]
British Journal of Community Nursing Vol 18, No 10
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on October 31, 2015. For personal use only. No other uses without permission. . All rights rese
CARE OF THE OLDER PERSON stigma. As a result of this, older gay men with HIV will encounter discrimination, rejection, prejudice and stereotyping as a result of the stigma associated with their real or supposed sexual orientation. In a discussion on American and Canadian attitudes, Andersen and Fetner (2008) note that because older adults tend to hold more conservative views on issues of gay rights and homosexuality, older HIV-positive adults may in turn experience difficulty in their relations with age peers. As a result, they may internalise their own feelings of guilt or shame regarding their HIV. There is no reason to suppose that these attitudes would not be the same or similar in the UK. Older gay men with HIV often become disconnected from their friends, family and society at large, with many men reporting feeling separated, alone, isolated and rejected by their community and peers (Power et al, 2010). Social isolation and a lack of social networks and support leaves older gay men living with HIV vulnerable as they have less resources and are more susceptible to negative outcomes such as: w Depression w Bereavement w Poor mental health w Substance abuse.
© 2013 MA Healthcare Ltd
Support from nurses As a result of the situation that may face older gay men living with HIV, there is a need for nurses, working as members of the multidisciplinary team, to contribute to the development of innovative support networks and systems that will support this vulnerable and growing group of patients. In so doing, nurses can ensure that they make the care of the person they are caring for their first concern, treating them as individuals and respecting their dignity (Nursing and Midwifery Council, 2008). Internalised homophobia, denial of risk, alcohol and other substance use, and anonymous sexual encounters are all HIV risk factors for older gay men. The challenge for nurses and others who provide health and social care is to engage, educate and assist them effectively in changing and maintaining safe behaviour when engaging in sexual and drug-using activities that can transmit HIV. Older gay men over the age of 50 have been, and continue to be, an invisible part of the HIV/AIDS epidemic. The reasons for this are many, but among them are societal beliefs, myths, and stereotypes emanating from ageism and homophobia. In addition, HIV/AIDS is sometimes misdiagnosed in older adults because many of its symptoms mimic other illnesses that affect older people. For example, Pneumocysis (carinii) jiroveci pneumonia can often present with an insidious onset of breathlessness and malaise. This is not always accompanied by pyrexia. In older patients, symptoms can mimic cardiac disease in the early stages. Oropharyngeal candidiasis, which relapses after satisfactory treatment whether or not there are associated gastrointestinal symptoms should raise suspicion of an underlying immune paresis (Pratt et al, 2010).
British Journal of Community Nursing Vol 18, No 10
Comorbidities and other conditions Gebo (2006) has demonstrated that there are toxic effects associated with long-term exposure to ARVs. These include a reduction in both the number of years a person can expect to live and in the quality of life of the person exposed to ARVs. The impact on ageing with HIV is so new that there is very little known about it from a biomedical perspective, particularly in terms of the impact on the older person. ARVs interact in a complex way with body systems. Effros et al (2008) suggest that even when the immune system is stabilised by the use of ARV therapies, HIV has the ability to accelerate the effects of ageing, especially in relation to cognition. Older people with HIV have a higher proportion of comorbidities, which means that issues associated with drug and disease interactions may apply. The issue of HIV medications and their interaction with other medications must be given serious consideration by those nurses who care for older gay men with HIV. Current research in this area is limited and further research would be beneficial.
Side effects of ARV therapy There are a number of benefits associated with the use of ARV drugs. However, as with many types of medication, ARVs are not without their side effects, and as older people are less able to metabolise ARVs there is a possibility that increased toxicity will occur (Gebo, 2006). However, the long-term use of ARV therapy can bring with it other issues for the older adult, which can increase a person’s risk of several comorbidities. Bhavan et al (2008) demonstrated that there is an increased risk of heart attack associated with longer exposure to ARV therapies, and protease inhibitors in particular. Some possible side effects that can occur from taking ARVs are as follows: w Liver toxicity w Osteoporosis w Pancreatitis w Lipodystrophy w Peripheral neuropathy w Build-up of lactic acid. Another common problem that corresponds with the rise of effective HIV therapies is the emergence of obesity (Bhavan et al, 2008). Wand et al (2007) note that symptoms related to heart disease, including abdominal obesity, insulin resistance and hypertension increased from 8.5% to 26.5% in HIV positive individuals after commencing ARV therapy (Bhavan et al, 2008). HIV infection and HAART have also been associated with hyperlipidemia, which carries with it another risk factor for heart disease (Simone and Appelbaum, 2008). The fact that drug interactions can cause further health complications particularly affects older people with HIV who, as the result of an increased frequency of comorbidities within this population, are likely to be taking two or more medications for a number of other conditions concurrently. The combination of ARVs may result in abnormal bone metabolism, with longer-term therapy having a greater effect on bone density as opposed to erratic or irregular regimens (Kirk and Goetz, 2009).
493
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on October 31, 2015. For personal use only. No other uses without permission. . All rights rese
CARE OF THE OLDER PERSON
The immune system Ageing can have significant effects on a person’s immune system. Coupled with HIV, this can lead to severe challenges. HIV reduces a person’s T-cell count, and Kalayjian and Al-Harthi (2009) note that this leads to HIV-positive individuals having a T-cell population that is similar to that of someone 20–30 years older, reducing a person’s ability to defend the body against infection.Antibodies in the immune system are reduced due to ageing (Effros et al, 2008), leaving the older HIV-positive adult with an increased risk of potentially life-threatening infections (for example, pneumonia). Martin et al (2008) have demonstrated that the immune systems of HIV positive older adults receiving ARV therapy do not recover as quickly as those of the younger adult population. Baker et al (2008) note that there is a relationship between a lower CD4 count and an increased risk of heart, kidney and liver disease, and cancer.
Cancer Older adults with HIV have a generally elevated risk of cancer when compared with the general population (Grulich et al, 2007), with significantly higher incidence of several kinds of cancer: w Melanoma w Leukaemia w Hodgkin’s lymphoma w Colorectal w Renal w Anal w Liver w Lung w Mouth w Throat. Cranston et al (2007) discuss the issue of anal cancer, which is rare in the general population.The rate of incidence increases to up to 40 times for HIV-positive MSM.
LEARNING POINTS w Community nurses and other health and social care workers will be required to provide support to the growing number of older HIVpositive gay men w Older HIV-positive gay men often experience a triple stigma related to ageism, public misunderstandings about HIV/AIDS and anti-gay prejudice w Nurses have a duty to understand how issues of sexuality, the physical and mental impact of social isolation, stigma and comorbidity issues can have negative outcomes on the health and wellbeing of the older gay man living with HIV
494
Non-AIDS-related cancers (NARCs) (including anal, lung and liver cancer) have become more common among people with HIV than AIDS-related cancers such as Kaposi’s sarcoma and non-Hodgkin’s lymphoma (Engels et al, 2008). Deeks and Philips (2009) note that the relationship between NARCs and HIV is currently not well understood; immunodeficiency is associated with greater risk of their development. People infected with HIV do not have increased risk of breast, colorectal, prostate or many other common types of cancer (Grulich et al, 2007). Nurses should ensure that screening for these cancers in older people living with HIV should adhere to current guidelines that are in use for the general population.
Mental health In the UK, poor mental health is the largest cause of disability. It is also closely connected with other problems such as poor physical health, and problems in other areas of life, such as relationships, education and work prospects. The Department of Health (DH) strategy for mental health (DH, 2011) makes it clear that if improvements to people’s lives are to be made, then improvements to their mental health and wellbeing will be required. Older gay men living with HIV are confronted with stigma from multiple sources, which intensifies the negative impact on health and wellbeing. Furthermore, HIV and ageing can have significant effects on the brain. Older adults with HIV are, on average, more susceptible to negative mental health outcomes such as depression, dementia and Alzheimer’s disease. Cherner et al (2004) indicated that older people with demonstrable levels of HIV in their spinal fluid were twice as likely to have psychological impairment as those with no detectable virus. Ances et al (2010) note increased ageing of the brain among individuals with HIV, as well as lower-than-normal blood flow to the brain, matching levels usually seen in people 15–20 years older. Older HIV-positive adults are more likely to be diagnosed with depression compared with the general population (Gebo, 2006). It has also been demonstrated that older HIVpositive people have a greater prevalence of substance use, with the rate of depression having been shown to increase with age (Gebo, 2006). The impact of the medication used in HAART on a person’s mental health is currently unknown. Myers (2009) suggests that ARV therapy could cause damage that increases the risk of Alzheimer’s disease, which is not normally associated with HIV. At least one study suggests that the use of some ARV medications is associated with depression and other psychiatric side effects (Simone and Appelbaum, 2008). Power et al (2010) found that older gay people living with HIV are fearful that social care services, care homes and sheltered housing might be HIV-prejudiced or homophobic. While the majority of respondents in their study thought highly of their HIV clinicians, many reported poor experiences in primary care. Respondents in the study stated that their highest future priority was for good-quality health and treatment information.
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The interaction of ARVs and cholesterol medications for those people who are co-infected with HIV and hepatitis can cause liver toxicity. This is a serious concern as there is an association between low CD4 counts and an increased risk of death from liver disease (Gebo, 2006).
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CARE OF THE OLDER PERSON The mental health needs of the older gay man living with HIV can often be overlooked by nurses and doctors who may focus their attention on the physical impact of HIV, in spite of the fact that depression can exacerbate immune system dysfunction (Karpiak and Shippy, 2006).
The role of the nurse The role of the nurse is to provide high-quality, safe and effective care to all.When caring for older gay men with HIV, care provision must be contextualised and related closely to the situation in which the nurse is asked to intervene. Mandatory training should be provided by employers that includes methods for providing good-quality care for older gay men with HIV that is sensitive to their needs. Nurses conducting assessments should be knowledgeable about the needs of older gay men with HIV so that these needs are taken into account during the assessment process. The nurse should ensure that older gay men with HIV have access to relevant advice concerning services, social groups and other resources. Nurses and other health-care staff should use open language when talking to patients to give older gay men with HIV confidence to be open about their sexual orientation. Confidentiality policies should be clear to all patients and make clear to older gay men whether or not they would like their sexual orientation to be included in their medical records. Nurses and other care workers who provide services to people in their home should never assume a patient’s sexual orientation. It is unacceptable for care and support staff to discuss their personal views about lesbian, gay and bisexual people or issues. In the residential care setting, care homes should apply the same polices and procedures to same-sex couples wanting to live together in care homes as heterosexual couples. Older same-sex couples should be allowed private time or be allowed to show affection for one another, as is the case for heterosexual couples. Clear policies on what is acceptable and unacceptable behaviour for residents should be developed.
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Conclusion Since the beginning of the epidemic over 30 years ago, HIV has been transformed from being a life-threatening disease to a chronic illness. Older HIV-positive adults can often experience a triple stigma related to ageism, public misconceptions about HIV/AIDS and anti-gay prejudice. As the number of HIV positive people aged 50 and older increases in the UK, appropriate measures must now be taken to ensure that the needs of this diverse population are met. Those who provide and commission care services must understand and make provision for the high incidence of comorbidities and the long-term effects of ARV therapies. The social context in which older gay men with HIV/ AIDS live, including the damaging effects of stigma on their physical health and emotional wellbeing, must also be given consideration as nurses strive to improve care. As most HIV research has generally focused on younger gay men, there is an urgent need for further research into this group of HIV-positive older men.
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