- September 18, 2013
Post submitted by Mark Brennan-Ing, PhD, Director for Research and Evaluation, ACRIA Center for HIV and Aging, NY, NY
Last week I returned from the U.S. Conference on AIDS (USCA) in New Orleans. I remember when the First Annual HIV and Aging Awareness Day was announced at that meeting in 2008, and this year there were many more HIV and aging sessions than in the last five years of the USCA. The topic of aging and HIV has been gaining attention since that first awareness day in 2008.
In 2010, there was a White House meeting on HIV and aging, and the following year the National Institutes of Health Office of AIDS Research formed a special working group to identify priority research areas. I was part of the working group that was tasked with focusing on societal infrastructure, behavioral health and caregiving issues. Two critical areas were managing multiple co-morbid conditions, a challenge that many who are aging with the virus face, and addressing the fact that depression in this group is five times higher than among HIV-negative older adults.
These two issues are particularly important in light of the spotlight at this year’s USCA on the HIV “treatment cascade” and changes to HIV care that will result from the full implementation of the Affordable Care Act (ACA) in 2014. “Treatment cascade, “as the CDC reported in 2012, is the term used to describe the fact that only 82% of the nearly 1.2 million people infected with HIV in the U.S. have been tested and diagnosed, only two thirds of them have been linked to HIV care, fewer than 40% are retained in HIV care, only a third are on anti-retroviral medication, and only a quarter have achieved viral suppression, which reduces the chances of developing co-morbidities and passing along HIV to someone else.
Many of the USCA presentations focused on structural mechanisms for improving the treatment cascade, e.g., care completion programs, replete with health navigators, case managers and other supportive services. Medicaid expansion under ACA should also improve access to care for those with HIV, providing stronger linkages to care, better retention in care and higher treatment adherence.
Curiously, however, there was little mention of how behavioral health issues like depression can interfere with even the best-laid plans for getting those with HIV into regular care and adherent to their medications. Depression is the most reliable predictor of care non-engagement and treatment non-adherence in the HIV realm, as well as of other chronic conditions that many aging with the virus will experience.
We still have little understanding of why depression continues to go unmanaged in this population. We do know that depression is triggered by HIV stigma, loneliness and social isolation. In fact, HIV stigma fuels loneliness and isolation as HIV-positive adults experience rejection by social network members and engage in self-protective isolation. Research on the social networks of older HIV-positive adults finds many with fragile, truncated social networks and high degrees of isolation.
The toxic effects of social isolation cannot be overstated. We recently completed the second phase of a pilot study on a telephone support intervention for older adults with HIV who are depressed, supported by the Mapplethorpe Foundation, which has provided a lot of insights into addressing this problem.
In talking with these clients, we found that most were connected to services, but were dissatisfied with a behavioral health system that often focuses on medication management of mental health without accompanying counseling and support. Many had been in and out of behavioral health services for much of their adult lives. Often depression was accompanied by substance use, which served as a further barrier to receiving treatment for depression (i.e., many mental health providers will not treat substance users until they have completed rehab). Most were not interested in taking any kind of psychotropic medication because such treatment had failed in the past and/or they felt they were taking too many medications already for their physical ailments. And, not surprisingly, many were extremely isolated, with little contact with family or friends.
The support intervention we provided, based on the MacArthur Foundation RESPECT model, consisted of a weekly support call by a trained care manager. It was meant more as a check-in call than therapy over the phone. Yet this simple intervention, which was in addition to other prescribed treatment, helped reduce depression symptoms significantly over a 6-month period. Many of the clients said that it made a big difference just to know someone was out there who “gave a damn.” Many also reported that they were making significant progress in staying engaged in care and being adherent to their medications.
Clearly, if we do not address the behavioral health needs of older adults with HIV, it is unlikely that we will ever improve the treatment cascade for this age group to the point where everyone who is diagnosed is successfully linked to care, remains in care and achieves viral suppression through medication adherence. I hope that by next year’s National HIV and Aging Awareness Day, we will be able to see some real progress in reducing the mental health disparities faced by people growing older with HIV.