"If you treat psychiatric disorders, [HIV] patients do better."
-- Glenn Treisman
Drawing on his work at Johns Hopkins, Dr. Glenn Treisman focused on three key mental health issues that influence HIV disease: depression, cognitive impairment and substance use, all of which may increase with age and affect treatment adherence, viral load and CD4 cell counts, inflammation in the central nervous system (CNS) and CNS infection.
Depression, Treisman said, is common in the setting of HIV infection -- occurring six to ten times as frequently in aging HIV-infected patients compared with the general population, he estimated. Unfortunately, he explained, depressed patients tend to be less adherent to antiretroviral therapy and other medical treatments and less likely to seek care. Depression can also worsen cognitive function (and be worsened by cognitive decline) and intensifies substance use disorders.
There is also good reason to believe that the virus itself can cause depression, Treisman said, citing studies that link HIV-induced cytokine activity and CNS inflammation to depression in a large subset of patients. HIV and depression thus appear to perpetuate one another: as Treisman put it, the virus "inflames your brain [and] causes depression. As you get depressed, you don't take your HIV medicines and, as you don't take your HIV medicines, your depression gets worse."
Another issue often faced by people aging with HIV is cognitive impairment. "Even though we're treating people, we still see them getting cognitively impaired -- it's just more subtle forms of cognitive impairment ... and the onset is more variable," said Treisman. People with cognitive impairment may experience a general slowing of their thought processes, along with poor coordination, memory loss and depression.
According to a recent study described in American Journal of Geriatric Psychiatry, cognitive impairment also has a greater effect on treatment adherence in older people, putting them at higher risk for drug resistance and poorer suppression of HIV.
HIV-associated dementia, an advanced form of cognitive impairment, is associated with elevated viral load in the central nervous system. New research is examining whether antiretroviral regimens that better penetrate the CNS may decrease the risk for HIV dementia -- as well as depression. Treisman cited unpublished data from Scott Letendre at the University of California, San Diego, whose research suggests that better CNS penetration of antiretroviral drugs is correlated with improved mood. With drugs that can reach HIV in the CNS and halt its replication there, Treisman said, "not only do we prevent dementia, but we may be preventing depression -- which isn't a surprise to those of us who subscribe to the 'cytokine idea' that depression is caused by elevated cytokines in your brain."
Substance use and addiction represent another mental health issue that disproportionately affects people aging with HIV, Treisman observed, although there is a lack of recognition among health providers that substance abuse is an issue for older patients. Chronic use of opiates such as oxycodone (OxyContin and other formulations) may not be considered "addiction," but it does affect cognition and has a negative effect on HIV health, Treisman noted. Substance-use treatment is a cost-effective but chronically underfunded intervention.
"We can get people better -- all of the things I talked about tonight are treatable," concluded Treisman. "Demand more resources for your patients, and raise a little hell when people say, 'They're old anyway.'"
"I never thought I would have to worry about this: Who is going to take care of me as I get older?"
-- Michael Siever
Following the presentations, the three panel participants gave personal accounts of some of the challenges they are experiencing as they get older with HIV. Dr. Michael Siever prefaced his comments by acknowledging that, being a white male from a wealthy country and having been fortunate enough receive and respond well to antiretroviral treatment, he speaks from a position of privilege and is extremely grateful to have lived long enough to face these challenges. Then he summed up some of the confusion felt by HIV positive people experiencing health problems as they get older: "Is it age or AIDS?"
Researchers are grappling with the same question about the interactions of HIV, HIV drugs and aging, but it is unclear just what the study findings mean to older HIV positive people. Siever spoke of the difficulty interpreting the flood of new research reports on HIV and aging, particularly around HIV-induced inflammation. As he put it, "sometimes too much knowledge is not very helpful."
Sylvia Young admitted that the challenges she encounters as an older HIV positive person sometimes seem endless. She related that a diagnosis of oral cancer the previous year led to three surgeries and loss of speech for two weeks, which in turn led to depression. She battled the depression with exercise, until the exercise caused debilitating fatigue. "It's one thing after another," she said.
All three panelists also talked about the stigma that older HIV positive people often encounter. As a gay man getting older with HIV, Siever faces homophobia, HIV stigma and ageism -- sometimes from within the gay community itself: "There's an incredible amount of ageism in the gay community, where we are, unfortunately, all expected to be young and beautiful and have rippling abs and all kinds of impossible things to have when you're 60."
In his clinical work, Siever sees increasing numbers of older gay men using alcohol and drugs as a way of coping with stigma. He finds it especially painful when older men who have recently "come out" turn to substance use to ease the transition into the gay community, or feel that they won't appeal to potential sex partners unless they offer drugs.
In her work with SWAPOL, Siphiwe Hlophe has seen HIV stigma provoke intimate partner violence. "The most important thing [is] disclosure to your partner," she said, relating that, in her experience, some male partners -- even those living with the virus themselves -- blame women for testing positive.
Hlophe was one of the first women in Swaziland to publicly declare her HIV positive status, and her organization now teaches women to fight stigma in the home and in their communities, as well as in health clinics, where SWAPOL-trained "lay counselors" help HIV positive women get better care as they age. Through SWAPOL, women gain the resilience to live longer with HIV.
"We empower women on issues of HIV and AIDS," Hlophe explained, "especially those over 60, who have started their income-generating project, so that you don't think about the disease -- you think about what you are doing now in order to earn a living."
Young offered a similar view: "In my work at WORLD, as a peer advocate working with women who are over 50 and HIV positive, I have seen challenges, but I also see resilience."
Working with a peer advocate, Young explained, helps older HIV positive women get better attention to their unique health needs -- such as starting menopause in their early forties, or dealing with arthritis and incorporating pain medication into their daily treatment regimen for HIV. "I have seen peer advocacy change the lives of positive women," she said.
"The good news is, we have to think about HIV and aging."
-- Amy Justice
So, what should advocates, providers, individuals, and communities be doing now to prepare for and meet the needs of an increasingly older HIV positive population?
Siever, Young and Hlophe agreed that a major advocacy priority is overcoming the misconception that HIV does not affect older people. They also emphasized the importance of addressing the larger issues of poverty, racism, sexism and ageism, all of which hinder efforts to prevent new HIV infections and improve the health and wellness of those already living with the virus.
Returning to the topic of mental health, Treisman noted that providers often hesitate to offer antidepressant medications to elderly patients because older persons tend to experience more side effects and are generally more resistant to taking psychiatric drugs. He and Justice concurred that, rather than following a single "recipe" for treating all HIV patients regardless of age, providers should tailor care for each individual. Treisman also encouraged providers to look beyond a patient's HIV to ensure that other conditions don't go untreated.
In a similar vein, Justice suggested that providers and individuals draw on resources outside of HIV medicine -- specifically, the field of geriatrics.
For example, falls prevention (such as removing throw rugs and other tripping hazards from the home) is one proactive step that older adults and their health care providers can consider.
"We should be thinking about bone mineral density and thinking about medications," said Justice, "but we also ought to think about the living environment that this person is in: Can we help them prevent having a fall rather than treating it after it occurs, when they have a fracture?"
Justice and Treisman agreed that other fairly simple measures -- such as promoting activities for mental stimulation and switching to clothing with easy-to-manipulate Velcro fasteners rather than buttons -- can help aging HIV positive individuals prepare for and cope with cognitive impairment. "There are lots of resources for elderly patients that are going to be necessary in somewhat younger HIV patients," Treisman concluded.
In terms of what communities can do, one audience member recalled the early days of the HIV epidemic in the U.S., when members of the gay community assumed caretaking responsibilities for their sick and dying friends. His suggestion for meeting the needs of an aging HIV positive population was simple but poignant: "It's time to take care of each other again."
|For More Information on Aging and HIV|
On October 13, 2010, San Francisco AIDS Foundation and several community partners held a public forum, titled "HIV & Aging: Now What?"
The forum brought together community members, advocates, health care and service providers and researchers for a dialog about the challenges of getting older with HIV and the latest research on HIV and aging.
This event was part of the foundation's HIVision forum series, which provides a safe venue for discussion of timely and potentially controversial topics in HIV prevention, treatment and care.
To download the executive summary of the forum and learn more about past and upcoming HIVision events, click here.
Manali Nekkanti, M.P.H., is a research associate at San Francisco AIDS Foundation.
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