Stephen Karpiak, PhDAssociate Director for Research

Mark Brennan-Ing, PhDSenior Research Scientist

AIDS Community Research Initiative of America ACRIA

ACRIA Center on HIV and Aging NY, NYNew York University College of Nursing

The Challenges of Multimorbidity Management

And Caregiving

HIV and Aging: The Challenge of the Epidemic’s Fourth Decade

2012 IAS Meetings

'85-87 '90 to '92 '95 to '97 '00 to '02 '03 to '05

24

24.327.1

33.2

Median Life Years at Age 20 With HIV In-Care

ART

• ARVs prevent the collapse of the Immune System

Good News

• Today there are 2 dozen ARVs Good News

• ARVs do not restore the immune system to normal levels

Reality

• ARVs do not prevent the cascade of inflammatory responses that are caused by HIV infection

Not Good News

ROAH1: 1000 HIV+ NYC Residents Age 50 and Older

Average Number of ComorbiditiesROAH1: 1000 HIV+ NYC Residents Age 50 and Older

Elderly 70+ROAH

0tan28a566028

0tan29a566029

0tan1a56601

0tan2a56602

0tan3a56603

0tan4a56604

0tan29a566029

0tan2a56602

Average Age= 55 Years

Brennan et al., 2009 n=1000 NYC HIV+ Over 50

% on Non-ART Medication by AgeSwiss Cohort N = 8575

<50 >65 p -value

Anti-Hyper not ACE 5.6 31.3 <0.001

ACE Inhibitors 11.1 32.9 <0.001

Lipid-Lower 12.7 41.8 <0.001

Oral Anti-diabetics 2.1 9.1 <0.001

Insulin 1.4 5.8 <0.001

Anti-platelet 5.8 28.9 <0.001

Anti-depressant 10 7.8 0.659

Hasse et al., ..Swiss HIV Cohort, 2011 CID53:1130-1139

Many Age-Associated Disease are More Common in Treated HIV Patients than in

Age-Matched Uninfected Persons

Cardiovascular disease

Cancers

Bone fractures; osteopenia

Left ventricular dysfunction failure

Liver Failure

Kidney Failure

Frailty

Immune System

These Illnesses Associated with Old Age Occur as a Result of MULTIPLE Increased Risks

CONTEXT

RISK• HIV

RISK• Gender

RISK• Substance Use History

RISK• Life Style: Exercise, Diet

RISK• ARVs

RISK• Other Co-occurring Illnesses

Multi-morbidity in HIV:Regional Factors

In North America and Europe:• HCV co-infection, alcohol, tobacco, and opioid abuse

In Africa:• Tuberculosis, malaria, obstructive lung disease (smoke

inhalation) and alcohol abuse

AAHIVM: Guides for the Management of Older Adults with HIV

American Academy of

HIV Medicine

American Geriatrics

Society

ACRIA Center on HIV and

Aging

Expert Panel of Leaders in HIV

Treatment Research and Geriatric Care

Dec 1, 2011

Summary report from the Human Immunodeficiency Virus and Aging Consensus Project: Treatment Strategies for Clinicians Managing Older Individuals with the Human Immunodeficiency Virus. J Amer Geriatrics Society 2012 May;60(5):974-9.

What are the implications of multimorbidity management ?

Achieving Optimal Health Must Include THE PERSONPatient Directed CareTheir Priorities andSupports must be considered

Multi-morbidity is overlapping injury to multiple organ systems. Geriatricians warn against the blind application of screening and treatment guidelines developed for primary care

The sum is greater than the parts.

Correlation Between Depressive Symptoms and Illnesses in Older Adults with HIV

•Vision Loss .160**

•Hearing Loss .094**

•Dermatological Problems .134**

•Heart Conditions .086*

•Respiratory .167**

•Stroke .059

•Diabetes .067*

•Broken Bones .079*

•Impotence .092**

•Neuropathy .049

Havlik, Brennan, & Karpiak …2011 p <. 05*, p <. 01**

Over 50-75% of study groups of older adults with HIV show moderate to

severe depression

Depression Causes Non-Adherence to ALL Medication

including HIV Meds

What is the most burdensome disease in the world today? According to the World Health Organization, the disease that robs the most adults of the most years of productive life is not AIDS, not heart disease, not cancer. It is depression.

According to the World Health Organization, three-quarters of the world’s neuropsychiatric disorders are in low-income or low-middle income countries.

Where health care professionals are few: task shifting…training and supporting people with lower levels of education to do the work of doctors and nurses.

Amadi was 59 lost five of 9 children… 3 of them to AIDS. She was numb and passive, sad and irritable.

She could not care for her family, work in her garden, or do her mat-weaving.

Using a faith-based group's infrastructure to recruit peer facilitators and the women

The study designed to test interpersonal therapy, proved as effective as medicine at curing major depression in Western settings.

The women all became active in the community, and each talked to her own family members about H.I.V. infection and how to prevent it.

Helena Verdeli, assistant professor of clinical psychology and director of the Global Mental Health Lab Columbia University’s Teachers College. NY Times Julky

• 18 weeks after starting …Amadi had no more symptoms of depression. She was once again, to use her husband’s words, the fierce, loving, strong woman she had been.

Caregiving

Mark Brennan-Ing PhDSenior Research Scientist

Background

Caregiving is a universal human experience – we will all provide care or receive care at some point in our lives (Rosalyn Carter)

Caregiving occurs in a social and cultural context, thus....

Caregiving in response to HIV varies by country, culture, availability of resources, etc…

Caregiving Issues in High Income Countries

• In resource-rich countries like the U.S., there has been wide-spread access to ARVs resulting in the aging of the population living with HIV

•This success has brought about the challenge of multi-morbidity:

• Multiple chronic illnesses result in disability and increase caregiving needs

• However, many lack caregiving resources and options

CAREGIVERSare derived from

SOCIAL NETWORKS

• Social networks are a significant healthcare resource

• Informal caregiving worth approximately 450 Billion

Dollars in the U.S. (AARP, 2009)

• PLWHA are both care providers and care recipients in

their networks

Need for Caregiving: PLWHA 50+ in the U.S.

Cur-rently Need Care19%

Needed Care in

Past19%

Have Not

Needed Care62%

Brennan, M., Karpiak, S. E., London, A. S., & Seidel, L., (2010). A Needs Assessment of Older GMHC Clients Living with HIV. http://www.acria.org/files/GMHCFinal.pdf

•Average Age= 55.5 Years

•Average Number Comorbid Conditions = 3.4

•46% reported difficulty with at least one Instrumental ADL

•22% reported difficulty with at least one Personal ADL

The Problem:Fragile Social Networks!

• The social networks of older adults living with HIV are fragile – lack of family involvement and reliance on friends, many who are also HIV+

• Fragile social networks result from:– Stigma

• Self-Protective Withdrawal (Emlet, 2006)

• Rejection due to stigmatized behaviors (e.g., drug use, homophobia) (Flowers et al., 2006; Lichtenstein et al., 2002; Mayers & Svartberg, 2001; Trzynka & Erlen, 2004)

– MSM are much less likely to have partner/spouse/children to rely on in times of need

Proportion Living Alone: ROAH vs. Community-Dwelling NYC Elderly

NYC Elderly 65+

ROAH

0% 10% 20% 30% 40% 50% 60% 70% 80%

39%

70%

1 Brennan, M., Karpiak, S. E., Shippy, R. A., & Cantor, M. H. (2009). Older adults with HIV: An in-depth examination of an emerging population. New York: Nova Science Publishers.

0 20 40 60 80

Parent

Child

Sibling

Other Relative

Friend

41.2

54

78.7

50.4

69.4

27.2

37.7

43.8

31.4

66.1

Living Functional

ROAH:Informal Network Composition

Caregiving Issues in Low Income Countries

• In resource-poor areas, such as Africa and Southeast Asia, the brunt of caregiving resulting from HIV infection is borne by older adults (age 50+)

• Older adults care for their children who are HIV-infected

• Older Adults care for orphaned grandchildren whose parents have died of HIV/AIDS

Caregiving in Sub-Saharan Africa (Bock & Johnson, 2008; Ogunmefun et al., 2011; Ssengonzi, 2007; 2009)

Older adults provide care to their HIV-infected children when illness at terminal stage

Caregiving for grandchildren begins before children are orphaned by parents with HIV

Most care is provided by women, resulting in higher rates of physical ailments and distress

These caregivers face severe economic strains and drastic disruption of living arrangements (i.e., frequent travel, absence from home)

Caregiving may result in secondary stigma

Caregiving in Southeast Asia (Kespichayawattana & Van Landingham, 2009; Knodel, 2008; Knodel & Wassana, 2004)

Similar to Africa, older adults provide care to their HIV-infected children when illness at terminal stage and also care for grandchildren

Women provide the bulk of care

Caregiving has a negative impact on finances by constricting time for economic activity (working)

Loss of adult children due to AIDS exacerbates the economic impact

Caring for grandchildren adds to this severe economic burden

ConclusionsCaregiving as a result of HIV/AIDS has a substantial impact in both high- and low-income countries

Women bear the brunt of this caregiving, and pay many of the consequences

As ARVs become more available in low-income countries, greater numbers of PLWHA will grow older and need care due to multi-morbidity

Caregiving can be invisible and undervalued

How can we best leverage caregiving resources and support those caring for PLWHA and their families?