October 26, 2016
David Fawcett, Ph.D., L.C.S.W., is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Fla.
We have not been here before. Over 50% of Americans with HIV are now over 50, and that number continues to grow. Mental health professionals treating older persons living with HIV are confronted with complex comorbidities that are just beginning to be documented and understood. When compounded by HIV, the routine medical, psychological and psychosocial stressors of aging grow more complex and present unique challenges to providers.
It is vital to increase the capacity of the HIV workforce to effectively identify and address the medical and psychosocial needs of aging persons living with HIV. Many survivors have been on antiretroviral therapy for over thirty years and have experienced a lifetime of stigma, shame and tremendous loss. Most thought that surviving to "old age" was a luxury they would never experience, causing many to lose a sense of purpose along the way. Amazing advances in HIV medicine have afforded thousands their lives -- albeit ones frequently complicated by mental health concerns, addiction and overwhelming psychosocial stressors.
We need culturally competent practices for this population, including not only assessment and treatment protocols but also prevention messages. Fortunately, critically needed new resources for professionals are emerging, an important step in the adaptation of the mental health workforce to meet the burgeoning needs of aging persons living with HIV/AIDS.
Mental health concerns among aging persons living with HIV/AIDS impact both physical and emotional health. The prevalence of depressive spectrum disorders, for example (which typically increase with age), is only amplified by HIV/AIDS. Up to 60% of persons living with HIV have had either major depression or dysthymia within a twelve-month period, according to various studies, and 26% to 47% experience some form of anxiety disorder in any given year. Persons living with HIV/AIDS have higher overall rates of addictive behaviors than the general population -- and this too increases with age. For example, it is estimated that 30% of older adults living with HIV/AIDS use illicit drugs. Substance misuse, along with mental health concerns, affect medication adherence and overall health status and compound the effects of psychosocial stressors such as isolation, perception of self-worth, stigma and shame.
HIV-Age.org, a website sponsored by the American Academy of HIV Medicine, the AIDS Community Research Initiative of America (ACRIA) and the American Geriatrics Society, provides regular updates on clinical issues specific to HIV and aging. One recent article, for example, provides two case studies of patients with HAND (HIV-Associated Neurocognitive Disorders), including learning objectives, clinical questions and detailed answers provided by experts, as well as resources for further reading.
Several recent HIV and aging toolkits are extremely useful for clinicians. The AETC (AIDS Education and Training Center) HIV and Aging Workgroup released a toolkit in 2015 with sections on prevention, assessment, treatment, and psychosocial complications. These components contain a variety of information summaries, video and infographics on various topics pertaining to aging and HIV/AIDS.
The Substance Abuse and Mental Health Services Administration (SAMHSA) HIV and Aging Toolkit was unveiled at the United States Conference on AIDS in September (disclosure: I was part of the development team for this toolkit). This resource contains four sections: medication management; life transitions and social challenges; co-occurring issues; and depression, anxiety and substance use. The toolkit is part of the HIV/AIDS and Mental Health Training and Resource Center, a SAMHSA-funded collaboration of the American Psychiatric Association, the American Psychological Association and the National Association of Social Workers.
Like other resources produced by the robust HIV/AIDS and Mental Health Training and Resource Center, this toolkit uses multiple formats to assist clinicians. The "Depression, Anxiety, and Substance Use" section, for example, is further divided into the following subsections: recognizing anxiety and depression, substance use and the role of the mental health provider. Each section includes bullet points, videos featuring both clinicians and a person living with HIV, and numerous links to external resources such as assessment scales from SAMHSA and others.
The HIV and Aging Consensus Project, sponsored by the American Academy of HIV Medicine and the American Geriatrics Society, published Recommended Treatment Strategies for Clinicians Managing Older Patients With HIV in 2011. This practice brief covers a wide variety of medical and psychiatric complications and provides assessment protocols and evidenced-based treatment guidelines.
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