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HIV & Aging - Mental Needs: Policy, Mental Health Services Program, Comorbidities, Services for Aging/Older HIV+
  Jules Levin, NATAP
The OAR & the NIH have increased funding for research in aging & HIV but what is lacking is a discussion about the problems older HIV+ individuals are & will be facing & theservices that will be needed.
inability to function: loss of income/housing, depression, increased substance abuse, emotional instability, suicide, non-adherence,
& increased comorbidities vs HIV-neg but less coping capacities:
falls/fractures, heart disease, diabetes, hepatitis, liver diseases, neurological/cognitive disorders, kidney disease, frailty
many research gaps need to be addressed, including a better conceptualization and measurement of successful aging and the development of high-quality integrated care, programs, and services tailored to the needs of older people with HIV. A more integrated policy response is needed to improve the psychosocial and economic well being of older people with HIV. The process of aging may be more challenging for people living with HIV than for the general population. This is because of the detrimental effects that HIV and its treatment have on normal aging processes as well as other factors, such as HIV-related stigma, loss of friends and social networks.....
The more medical comorbidities someone experiences, the poorer their quality of life.......Older people with HIV often compare themselves to their HIV-peers and report experiencing an earlier and more rapid decline in health, which increases anxiety about the future......In a United States multistate study, 94% of people with HIV aged 50 years or older (n = 452) had at least one other chronic illness, with an average of three comorbid conditions (including depression) [13]. Commonly reported chronic illnesses included high blood pressure (46%), chronic pain other than headache and back pain (45%), hepatitis (39%), arthritis (35%), diabetes (21%), and major depression (14% reported symptoms consistent with major depression). The presence of more chronic conditions was also associated with decreased functioning
About 50% of people living with HIV will develop HIV-associated neurocognitive impairments and disorders (HAND)......healthcare providers, front-line workers, and policy makers should have a greater understanding of the experience of aging with HIV......policy makers......HAND can have damaging effects on older adults' psychosocial well being.......uncertainties include concerns regarding the ability of healthcare providers to provide high-quality care at the intersection of aging and HIV; the financial situation and transition to retirement, including adequate pension; the availability of appropriate long-term housing; and the decreasing ability to care for themselves [20·]. In addition, older adults with HIV often need to negotiate multiple identities and the resulting stigma(s) attached to those identities, including ageism, homophobia, and HIV-related stigma [12,18]. Although ageism plays a role in the overall stigma experienced by older adults with HIV, some also report experiencing stigma and rejection from their HIV- contemporaries [19]. Many express concerns about being discriminated against by other older people if they have to move into old-age care facilities [18,20·]. Whereas disclosure is important for people with HIV to receive social support, perceived and internalized stigma affects disclosure among older adults living with HIV.......http://www.natap.org/2014/HIVAGE/061614_02.htm
novel cognitive deterioration could be prevented by high CNS penetrating regimens......http://www.natap.org/2013/CROI/croi_169.htm.......Patients with clinical deterioration had a lower CPEs both at inclusion (6.9 vs 8.1, p=0.005) and at the end of FU (7.2 vs 7.8, p=0.07) than those with improved or stable performance. This was confirmed by multivariate analysis.
NCI was associated with being on ART only in the CART era.....High rates of mild NCI persist at all stages of HIV infection, despite improved viral suppression and immune reconstitution with CART......."Pattern of NCI also differed: pre-CART had more impairment in motor skills, cognitive speed, and verbal fluency, whereas CART era involved more memory (learning) and executive function impairment......http://www.natap.org/2012/HIV/082012_02.htm
Integration of HIV primary care and mental health [http://www.natap.org/2013/HIV/052613_03.htm] provides the opportunity for both improving early detection of MNS co-morbidities with HIV infection and implementing effective interventions appropriate for existing health, family, and community resources. The evidence for the need is clear, and the evidence base for interventions suggests that it is feasible in low-resourced settings. Ultimately, successful integration of HIV and mental health services will require shared commitment of providers and policymakers along with collaborative learning to address remaining challenges.
At a minimum, packages of care for selected MNS disorders should be included when scaling-up HIV primary care prevention and treatment services.......Use Evidence-based Interventions when Integrating HIV and MNS Disorders Evidence-based mental health interventions.........HIV directly affects the central nervous system (CNS), with increasing evidence of long-term cognitive effects that may, despite achievement of non-detectable viral load, not be reversible with currently available cART
integration requires actions directed at people seeking services, local providers, and regional or national health care systems [41]. Persons seeking services should be viewed as partners whose needs for medical care, social inclusion, and psychological support will be addressed through the integrated services
Mental, neurological, and substance use (MNS) disorders occur frequently in patients with HIV and are associated with negative outcomes, including reduced adherence to antiretroviral medications (cART), and diminished quality of life
MNS disorders may occur at rates that exceed those of physical co-morbidities [1]. Depression is twice as common in people living with HIV (especially when symptomatic) than in uninfected individuals
HAND prevalence ranges from 20% to 56% worldwide, and is especially high in older patients and those with advanced immuno-suppression. In low-income countries, HAND is compounded by poverty, opportunistic central nervous infections, and assessment challenges [6],[7].
A variety of mechanisms links MNS disorders to HIV disease. First, the social conditions under which most patients with HIV live (e.g., limited employment, housing and food insecurity, exposure to stigma, and fear of serostatus disclosure) contribute to the development and exacerbation of MNS disorders [8]. MNS disorders, in turn, are associated with greater suffering, including poorer psychological adjustment to a chronic, progressive and life-threatening illness; lower quality of life [9],[10]; worse HIV treatment adherence and outcomes [5],[6]; and an increased risk of HIV transmission [11].
Second, HIV co-morbid substance use disorders can influence HIV transmission by increasing vulnerability to sexual exploitation and impairing the judgment required to engage in safe sexual practices [11],[12]. Third, HIV directly affects the central nervous system (CNS), with increasing evidence of long-term cognitive effects that may, despite achievement of non-detectable viral load, not be reversible with currently available cART [13]. HIV also puts individuals at risk for acquiring other infectious and non-infectious conditions that affect the CNS-including malaria, tuberculosis, and lymphomas -and further impair CNS function [7].
Meta-analyses of studies of collaborative management of depression in general primary care show improvement in baseline depressive symptoms (standardized mean difference = 0.34), adherence to depression treatment (odds ratio [OR] = 2.22) and response to treatment (OR = 1.78) [16], with strong support for these effects across a broad range of primary care settings, including in low-resourced settings [17],[18].
Additional evidence demonstrates the cost-effectiveness of integrating interventions for depression and alcohol abuse in primary care [19],[20]. Improving the understanding of core processes and components of such integration is important, however, to ensuring its success. The focus of this discussion are the challenges to integrating mental health services into primary HIV care, with an emphasis on studies in low- and middle-income countries, using the summary principles of the GCGMH: use of a life course approach, use of evidence-based interventions, understanding environmental influences, and use of system-wide approaches to alleviate suffering.
Use Evidence-based Interventions when Integrating HIV and MNS Disorders Evidence-based mental health interventions are available that can be delivered in non-specialist mental health settings, making them potentially ideal for HIV care settings or for primary care. Effective screening instruments to facilitate diagnosis and pharmacological and psychological treatments exist for depression [29],[30]. Empirically supported psychosocial treatments for depression, including cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and problem-solving therapy (PST), have been studied in the context of HIV in resource-rich [30] and -limited countries [29],[31],[32]. Such therapies can be delivered to individuals or groups, with the number of sessions planned based on the level of psychopathology and treatment goals. Many protocols use between 2 and 20 sessions. Intervention outcomes vary and include reduced severity of depressive symptoms, increased positive coping, facilitation of support networks, and increased self-esteem [30],[32]. Good outcomes have been demonstrated when non-specialized primary health care workers [33] and trained lay providers [32] deliver interventions. CBT and PST can also be used to address problems or goals associated with health-related behavior change, such as adherence to antiretroviral therapy [34].
Screening for hazardous alcohol use [and substance abuse] [This study identified high rates of illicit drug use among HIV-positive adults aged 50 and older.....drug use may be over two times higher in HIV-positive compared to HIV-negative older adults.......http://www.natap.org/2014/HIVAGE/061614_03.htm]combined with brief interventions (SBI) includes providing feedback on assessed levels of drinking; communicating potential deleterious effects; recommending reducing levels of alcohol consumption; and, where necessary, referring for specialized care
The diagnosis of HAND in primary care is complicated by a lack of instruments validated across cultures and literacy levels [7]. The International HIV Dementia Scale, which translates well across cultures, assesses more motor-based skills and is not as useful for less severe levels of impairment [7]. Milder levels of neurocognitive impairment in children and adults may best be detected through interviews with partners, close family members, and patients to examine changes in social, home, school, or work functioning over time or, for children, to make comparisons with same-age peers. Early recognition of HAND, particularly in children, provides an opportunity for rehabilitative interventions.
Computerized cognitive rehabilitation therapy, based on an intervention developed to improve working memory and executive function, is one still experimental intervention that is feasible in a low-resourced setting and demonstrates neuropsychological and psychosocial benefits in children with HAND [37]. While antiretroviral drugs vary in their ability to penetrate the brain, it is not yet clear if treatment with cART with higher compared to lower brain penetrance can prevent the more subtle but clinically significant forms of HAND. Some evidence exists that higher penetration cART improves survival in children, whether or not they develop HAND [38]. Moreover, there is potential to task-shift by involving existing lay counselors working in basic HIV treatment settings in low-resourced contexts in the provision of ancillary services, such as helping parents recognize that affected children may need additional help with school work or more step-wise explanation of household tasks/chores to prevent additional educational, social, and emotional problems.
HIV & Aging: Failure to Normalize Immunity Despite Decade of Successful HAART - (06/16/14)
HIV & Aging: HIV and the aging kidney - (06/16/14)
HIV & Aging: Biologic aging, frailty, and age-related disease in chronic HIV infection - (06/16/14)
HIV & Aging: Immunosenescence and aging in HIV - (06/16/14)
HIV & Aging: Update on metabolic issues in HIV patients - (06/16/14)
HIV & Aging: Coping styles and illicit drug use in older adults with HIV/AIDS - (06/16/14)
HIV & Aging: Psychosocial, mental health, and behavioral issues of aging with HIV - (06/16/14)
HIV & Aging: Demographics of HIV and aging - (06/16/14)
HIV & Aging: African Americans, Hispanics, Caucasians (2 MACS Studies) - (06/09/14)

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