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The Challenges of Multimorbidity Management And Caregiving HIV and Aging: The Challenge of the Epidemic’s Fourth Decade 2012 IAS Meetings. Stephen Karpiak, PhD Associate Director for Research Mark Brennan-Ing, PhD Senior Research Scientist - PowerPoint PPT Presentation
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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?