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Aging Successfully in WIHS...BUT. Prevalence and Correlates
of Self-Rated Successful Aging Among Older Women Living With HIV
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Download the PDF here
Rubtsova, Anna A. PhDa; Wingood, Gina M. ScDb; Ofotokun, Ighovwerha MDc; Gustafson, Deborah PhDd; Vance, David E. PhDe; Sharma, Anjali MD, MSf; Adimora, Adaora A. MDg; Holstad, Marcia PhDh
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Yes, I certainly believe Successful Aging (SA) is possible & achievable. No one argues this point. However, sorry but I must raise some clear & obvious concerns not addressed in this analysis. First, the study does not look at SA by age group, this study average age is 57, and the paper says range of age was 50-81. Since they did not stratify by age we do not know if women (OWLH) over 65 had worse aging, and we do not know if aging was worse depending on how many comorbidities one has because they did not look at that either; they did not either look at cognitive impairment. Third, Aging & HIV cutoff for age problems us NOT 50, although thats the age everyone likes to use, its 60 to 65, really 65. Its at this age, usually 65, where the aging impact kicks in more, that is when comorbidities start to emerge more often, I find that when one is still in their 50s the aging syndrome is much less, but after 65 it can really kick in. Studies show us HIV+ experience about 10 years of earlier biological aging vs HIV-neg. Brain function, cognitive impairment and others all occur earlier & at greater frequency in older HIV+. At Mt Sinai HIV clinic in NY they says almost all HIV+ patients over 60 have some degree of cognitive impairment. Finally, it is fine that spirituality & resilience can & does help, and I agree, as Mike Tyson’s often used quote “everyone has a plan until they get punched in the face” says when you get debilitating cancers, heart disease, kidney disease, mental & physical disabilities it is THEN you have a problem; I don’t see that studied in this study, what about the significant percent who get hit hard by comorbidites, are they as resilient? I say you are resilient until you’re not. This study finds about 83% of older women with HIV in WIHS (where there is more support than in the clinic) say they are "Successfully Aging”, which means 17% said they are not, so what happens once these women start to really get bad comorbidities, which might happen after 65 or 70, at a more accelerated pace than for aging HIV-neg ?, and what about men & women outside of WIHS where MANY HIV+ over 60 report they are not getting the support, care & services they need & they report feeling horrible & not aging well?? I know many PLWH over 60 really suffering with the aging “syndrome” who would not say they are Aging Successfully, they suffer mental & physical impairment, bone disease & fractures, cognitive impairment, heart disease, kidney dysfunction or advanced kidney disease, all of which occurs earlier & more often for PLWH. SO YES Successful Aging & encouraging attributes that promote them like residence & spirituality is a great concept, until people start getting sick & disabled & cannot function well mentally or physically. There are many like this in NY & SF where they have become homebound - unable to shop for & prepare food, unable to pay their bills & get evictions because they are too cognitively impaired & unable to normally function daily activities, and unable to make doctor visits, unable to navigate the healthcare systems & feel abandoned - many feel this. So yes positive approaches to aging should be encouraged, just as HV Geriatric Clinics should be integrated into every HV clinic, but this is a partial answer, it does not address the need for better care, better services & access to services & better support systems for those aging with HIV. This study distracts from these needs. CDC reports 300,ooo in US with HIV are over 60 years old & 70% over 40, this is the new reality, the entire HIV population in the USA is aging rapidly, soon 75% will be over 50 & 40% over 60, we are NOT prepared to deliver the care & services they need. Plus, reimbursement limits by insurers forces all HIV clinics to several & harshly limit medical visits to 20 minutes & limit doctors time they can devote to all patients needs, never mind the 70 year old with 10 comorbidities who needs extra time & attention, until this changes out HIV care system will fail sick elderly HIV+. Jules Levin NATAP
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Prevalence and Correlates of Self-Rated Successful Aging Among Older Women Living With HIV
Rubtsova, Anna A. PhDa; Wingood, Gina M. ScDb; Ofotokun, Ighovwerha MDc; Gustafson, Deborah PhDd; Vance, David E. PhDe; Sharma, Anjali MD, MSf; Adimora, Adaora A. MDg; Holstad, Marcia PhDh
Abstract
Background:
Despite marked gains in longevity attributable to antiretroviral therapy (ART), older women living with HIV (OWLH) experience substantial health challenges, and few studies addressed whether they can achieve successful aging (SA). This is among the first studies examining prevalence and psychosocial correlates of self-rated SA (SRSA) among OWLH and women at risk of HIV.
Methods:
The sample included 386 OWLH and 137 HIV-seronegative women enrolled in the Women's Interagency HIV Study (WIHS) who were aged 50 years and older and participated in the “From Surviving to Thriving” (FROST) substudy. The FROST survey included measures of SRSA and positive psychosocial constructs.
Results:
Participants were on average 57 years (SD = 5.3), 74% African American and 30% unemployed. Among OWLH, 94% were on ART and 73% were virally suppressed. Compared with OWLH, a higher proportion of HIV-seronegative women had an annual income ≤ $6000, no health insurance, and reported lower optimism and health-related quality of life. We found no differences in SRSA prevalence by HIV status: 84% of OWLH and 83% of HIV-seronegative women reported SRSA ≥7 (range = 2–10, higher scores signify better SRSA). Having SRSA ≥7 was associated with higher levels of positive psychosocial characteristics (eg, resilience and optimism) among both OWLH and HIV-seronegative women.
Conclusions:
SRSA is achievable among older women with and at risk of HIV despite health complications. Among disadvantaged women, factors other than HIV may be primary drivers of SRSA. Future research is needed to examine determinants of SRSA and to design public health interventions enhancing SA within this population.
INTRODUCTION
Older women (age 50+) living with HIV (OWLH) remain underrepresented in research1 despite the fact that their numbers have been steadily growing. The estimated prevalence of OWLH per 100,000 US population increased from 94.7 in 2007 to 172.8 in 2015.2,3 Over 102,000 US women aged 50 years and older lived with diagnosed HIV infection at the end of 2015.3 This increase is due to the combination of new HIV diagnoses in older people and increased longevity with the advent of antiretroviral therapy (ART).4 Despite this gain in longevity, OWLH experience complications related to the interaction of HIV and aging, such as the increased likelihood of multimorbidities, frailty, and polypharmacy, as well as substance abuse, social discrimination, and stigma.5–7 Little is known about whether successful aging (SA) is achievable for this population.6
SA was initially defined by Rowe and Kahn,8 in contrast to “usual” aging as the absence or avoidance of disease and disability, retaining a high level of physical and cognitive function and active engagement with life.9 However, this definition has been criticized as unattainable for marginalized populations, such as minority women and people living with HIV (PLWH).10–13 Thus, subsequent literature shifted its focus to self-perceived or self-rated SA (SRSA) defined as individuals' own holistic appraisals of how well they are aging; it is usually measured by asking the respondents how successfully they have aged on a 1–10 scale.14,15 Although SA as defined by Rowe and Kahn8 may be harder to achieve for socially and economically disadvantaged social groups whose aging can rarely be free from disease and disability, SRSA may be possible even in the presence of comorbidities.10,16,17
In fact, Raeanne Moore et al15 suggested that SRSA is achievable among PLWH. Although HIV-seronegative participants in this study experienced significantly higher SRSA prevalence and mean scores, the prevalence of SRSA among PLWH was high at 66%. Similar results were obtained in a study by David Moore et al.18 These findings are corroborated by qualitative research, which suggests that PLWH may be less concerned with the avoidance of disease and disability in their definitions of SA but focus on staying positive, caring for others, and maintaining self-care, independence, and engaged lifestyle.19–23 Furthermore, studies found that although SRSA was not associated with any HIV disease characteristics (eg, viral load) or sociodemographic factors, better SRSA scores were significantly associated with better health-related quality of life (HRQOL) and positive psychosocial factors, such as resilience and optimism.15,18 It is important to note, however, that the aforementioned studies examining SRSA among PLWH were implemented in the samples that were predominantly men and white. Few studies address SRSA among OWLH.
Importantly, observations among mostly white male samples cannot be generalized to OWLH, who are not only demographically different but also experience unique biomedical and psychosocial challenges.24 At year-end 2015, 58% (59,417) of OWLH were African American and only 18% (18,540) were white.3 Thus, most OWLH belong to ethnic/racial minorities, which often intersects with other social vulnerabilities, such as poverty, domestic violence, racial discrimination, and barriers to health care.1 Compared with HIV-seropositive men, OWLH also experience added burdens of gender-based inequality and stigma, as well as lower levels of sexual activity and poorer sexual health.24,25 Research additionally uncovers sex disparities in HIV-related health outcomes with women generally faring worse than men, partially because of differences in quality of and access to care.26 Thus, women lag behind men in terms of ART prescription, use, and adherence as well as viral suppression, with only 48% being virally suppressed in 2014.27,28 Research shows that compared with HIV-seropositive men, women have worse HRQOL and greater HIV-related morbidity and HIV-related and all-cause mortality.26 Among aging PLWH, female sex also increases the likelihood of such geriatric outcomes as frailty and falls.29,30 Moreover, OWLH face sex-specific health challenges, such as menopause and the increased risks of low bone mineral density and postmenopausal osteoporosis, perhaps exacerbated by the interaction of HIV infection, aging, and ART.31 Given these described disparities, it is reasonable to expect that SRSA will be less prevalent among OWLH than among white HIV-seropositive men.
The aim of this study was to examine the prevalence and correlates of SRSA in a sample of OWLH and, as a comparison group, older HIV-seronegative women enrolled in the Women's Interagency HIV Study (WIHS). Based on the findings described previously,15,18 we hypothesized that OWLH will have lower prevalence and lower mean SRSA scores as compared to HIV-seronegative women. We also expect that better SRSA scores will be associated with higher levels of positive psychosocial factors.
RESULTS
Sample Description
Participants were, on average, 57 years old, predominantly African American, unemployed, and not married or partnered, with no difference by HIV status (Table 1). More than one-third (38%) of participants in both groups had high school or less education. However, we found several significant group differences indicating that HIV-seronegative women in our sample may be somewhat more disadvantaged than the OWLH. A higher proportion of HIV-seronegative participants had very low annual income of $6000 or less, had no health insurance, and did not live in their own home. As compared to OWLH, a higher proportion of HIV-seronegative counterparts reported substance use, lower HRQOL, lower level of optimism, and higher level of perceived lifetime discrimination. OWLH in our sample had well-controlled HIV disease: 94% reported ART use, 73% had an undetectable viral load, and the median CD4 cell count was 750 cells/µL (IQR = 538; 1051).
SRSA Prevalence
We found no HIV group differences in any of the 3 measures of SRSA (Table 1). Moreover, the 3 measures were highly and significantly correlated; the Cronbach alpha was 0.67. Therefore, we focus our discussion on the subjective rating of SA because this is the measure that was used by previous research among PLWH. The mean score of subjective rating of SA among OWLH was 8.1 (SD = 1.73) and among HIV-seronegative participants was 7.9 (SD = 1.80). Moreover, similar proportions of OWLH and HIV-seronegative participants had scores ≥7 (83.7% vs. 82.5%; Fig. 1).
SRSA Correlates
Among the OWLH subsample, the adjusted logistic regression models showed relationships between multiple psychosocial factors and dichotomized SRSA (Table 2). The increased adjusted odds of SRSA ≥7 were significantly associated with the higher levels of the following positive psychosocial factors: personal mastery, optimism, resilience, spirituality, social support, coping, and HRQOL. Conversely, higher levels of anxiety, depression, loneliness, and history of lifetime discrimination were associated with the reduced adjusted odds of SRSA ≥7. Thus, OWLH with current depressive symptomatology had 54% lower adjusted odds of SRSA $7 as compared to OWLH with no depressive symptomatology (P < 0.05). Please note that although we present results for continuous measures of anxiety, social isolation, and lifetime discrimination, as reflected in Tables 1 and 2, we also tested associations with the following dichotomous measures: moderate to high level of anxiety (GAD-7 ≥10), any lifetime discrimination (Everyday Discrimination Scale score >0), and above the median loneliness (R-UCLA score >3). These analyses produced results similar to those presented. All of the aforementioned logistic regression models were adjusted for age, living in own home, some college or higher education, former cigarette smoker status, and consuming >7 alcoholic beverages per week. Of potential sociodemographic and biomedical (including HIV disease characteristics) covariates considered, only some college or higher education was associated [odds ratio (OR) = 2.2, 95% confidence interval (CI): 1.11 to 4.23, P = 0.02] with dichotomized SRSA among OWLH, whereas living in own home, some college or higher education, former cigarette smoker status, and consuming >7 alcoholic beverages per week approached significance at P ≤ 0.10 level. Age was not associated with SRSA ≥7 but was included as a covariate in the adjusted logistic regression models because of its theoretical importance.
Similar results were obtained in the HIV-seronegative subsample (Table 2). Of the 7 positive psychosocial characteristics considered, 6 were significantly associated with increased adjusted odds of SRSA ≥7, whereas HRQOL approached significance (adjusted OR (aOR) = 1.02, 95% CI: 1.00 to 1.04, P = 0.07). Of the mental health and traumatic events considered, having depressive symptomatology and higher levels of loneliness were associated with the reduced adjusted odds of SRSA ≥7. These analyses were adjusted for age, African American race, annual income ≤ $12,000, and abstainer from alcohol. Of all sociodemographic and biomedical variables considered as potential covariates within the HIV-seronegative subsample, only annual income ≤ $12,000 was significantly associated with SRSA ≥7 (OR = 0.31, 95% CI: 0.11 to 0.88, P = 0.03), whereas African American race and abstainer from alcohol approached significance at P ≤ 0.10 level in the unadjusted models. Similar to OWLH subsample, age was not significantly associated with SRSA ≥7 but was included as a covariate in the adjusted models because of its theoretical importance.
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