HIV/AIDS interventions for midlife and older adults: current status and challenges

Drawing on both domestic and global international perspectives, this special issue is devoted to articles that confront the challenges of understanding, preventing, and intervening, with HIV/AIDS as an epidemic that carries increasingly serious consequences for a growing number of adults who are 50 years of age or older. This issue builds on papers first presented at an HIV/AIDS and aging conference sponsored in the fall of 2000 by the National Institute on Aging of the National Institutes of Health. The editors have selected articles that focus dually on what is currently known and what needs to be known to successfully address the needs of persons 50 years of age or older who are vulnerable to the virus's effects. This special issue is organized around a series of subsections representing key issues and research findings related to HIV/AIDS and aging issues, including the epidemiology of HIV/AIDS and aging, HIV/AIDS risk and risk behavior, settings and situations as social contexts of risk, clinical challenges with older populations, living with and managing HIV/AIDS, interventions and research methods, new frontiers and challenges, and strategies for action. Some articles are data driven, whereas others are reflective pieces that recount personal experiences in living with the virus or point to new directions for research and practice. In this introduction, the editors highlight findings and approaches from each article and further add to our knowledge by setting these articles within the context of major themes relevant to the study of HIV/AIDS in an aging population.     

在HIV/AIDS小组心理治疗的实践

目的：在HIV／AIDS患者中开展小组心理治疗。探索经验和方法。方法：采用支持、认知为导向的集体心理治疗方法，对三位HIV／AIDS个体进行心理治疗。结果：三位患者在小组治疗后认同HIV身份之时，接纳自己，面对现实、减轻了孤独感。结论：在HIV／AIDS人员中实施集体心理治疗将有利于提高其生活质量。     

Potential interventions for HIV/AIDS wasting: an overview

Although the HIV wasting syndrome has become a far less common manifestation of advanced disease since the introduction of highly active therapies, much has been learned about a number of potential therapeutic interventions. HIV wasting therapies are reviewed. The evaluation of some of these treatments for management of body habitus alterations associated with antiretroviral therapies may be appropriate.     

Perceived barriers to social support from family and friends among older adults with HIV/AIDS

Research has found that HIV-infected adults age 50 and older are more socially isolated than younger HIV-infected individuals. This study examines the perceived barriers to obtaining emotional and practical social support from friends and family among 63 older adults (age 50+) living with HIV/AIDS. Many reported they did not receive enough emotional support (42%) or practical assistance (27%). Barriers to obtaining support included: (1) nondisclosure of HIV status; (2) others' fear of HIV/AIDS; (3) desire to be self-reliant and independent; (4) not wanting to be a burden; (5) unavailability of family; (6) death of friends to AIDS; and (7) ageism. These barriers may explain the greater social isolation of HIV-infected older adults and inform interventions targeted at reducing these barriers.     

Attitude of Lesotho health care workers towards HIV/AIDS and impact of HIV/AIDS on the population structure

Background

The impact and management of HIV/AIDS in Lesotho in the context of disaster management was investigated.

Objectives

Lesotho health care workers'' perception on HIV/AIDS progression, whether HIV/AIDS was managed as a disaster, and the impact on the demographic profile was investigated.

Methods

The empirical investigation included a literature study, and primary and secondary data analyses. Questionnaires (n=116) determined health care workers'' perception of HIV/AIDS. Interviews with officers of Lesotho Disaster Management determined how HIV/AIDS was managed as a disaster. National population censuses and data from surveys were summarised to describe the impact of HIV/AIDS on the population structure.

Results

Respondents'' modal age group was 25 to 39 years, 28.4% viewed HIV/AIDS related deaths as very high and perceived that HIV/AIDS changed the age composition, sex and dependency ratio of the population. Although HIV/AIDS was declared a disaster, the Lesotho Disaster Management Authority only aided the National AIDS Commission. There was evidence that HIV/AIDS caused the population pyramid base to shrink, and an indentation in the active population.

Conclusion

Health care workers attributed HIV/AIDS to changing the demographic profile of Lesotho, also reflected in the population pyramid. Lesotho Disaster Management Authority played a supporting role in HIV/AIDS disaster management.     

A profile of U.S.-based trials of behavioral and social interventions for HIV risk reduction

We describe 99 (experimental and certain quasi-experimental) U.S.-based trials, reported or published since 1988, of behavioral and social interventions that measured prespecified behavioral and biologic outcomes and aimed to reduce risk for HIV infection. Studies identified through June 1998 by the HIV/AIDS Prevention Research Synthesis project were grouped into 4 risk behavior areas: drug-related (k [number of studies] = 48), heterosexual youth (k = 24), heterosexual adult (k = 17), and same-sex (k = 10). We compared the studies in the 4 areas by variables key to the development, evaluation, and transfer of interventions. Participants comprised injection drug users (43% of studies), drug users out of treatment (29%), African Americans (18%), clinic patients (18%), youth in schools (10%), and drug users in treatment (10%). Most studies were randomized (85%), provided another intervention to the control or comparison groups (71%), and evaluated behavioral interventions (92%). On average, interventions were conducted in 5 sessions (total, 8 hours) during 3 months. The theoretical basis of the intervention was not noted in 57% of the reports. At least one variable from each of the 3 outcome classifications was measured in 8% of the studies: behavioral, biologic, and psychosocial. Distinct profiles exist for the 4 risk areas. Addressing gaps in research and reporting would be helpful for analytical and program activities. This sizable portfolio of evaluated interventions contributes to effectiveness reviews and to considerations of transfer to program practice.     

Women with HIV/AIDS: treating the fastest-growing population

AIDS is essentially the same disease in men and women, but a combination of social, psychological, and physiologic factors appear to define HIV disease and AIDS in women and suggest that different approaches may be needed for female patients. The likelihood that a woman will receive, adhere to, and respond to antiretroviral therapy differs from that among men. Specific psychosocial issues serve as barriers to treatment and adherence in women. Gender differences in CD4+ counts and viral load may warrant revisions of standard treatment guidelines, which were originally developed for men. Physicians need to understand gender differences in the course of AIDS, treatment responses, and the efficacy of newer antiretroviral drugs. Earlier diagnosis of HIV infection and AIDS in women may hinge on recognition of gender-specific AIDS-defining illnesses. Development of once-daily, tolerable, safer pharmacologic agents with distinct resistance profiles might improve adherence and efficacy of treatment in both men and women.     

HIV/AIDS behind bars: an avenue for culturally sensitive interventions.

The prevalence of HIV infection and the incidence of AIDS are higher among prison inmates compared to the general population. Although African Americans and Hispanics constitute approximately 13% and 12.5% of the population, respectively, they are over-represented among the prison population. The current trend in the adult/adolescent AIDS cases among African Americans and Hispanics outpaces that of the white population. The sociodemographic data of HIV/AIDS looks similar to the sociodemographics of U.S. prisons. This suggests that there may be a link between HIV transmission in prison and the current AIDS epidemic in the community. In addition, this high incidence is also a reflection of the high-risk lifestyle of the incarcerated population. High-risk behavior common among the incarcerated and inner city minority communities includes injection drug use, sharing of drugs and drug paraphernalia, and multiple sex partners. HIV transmission risk-reduction efforts such as mandatory screening of inmates, preventive HIV/AIDS education, and appropriate and adequate therapeutic management are essential to curtail the epidemic. However, any HIV/AIDS reduction program for minority communities must include culturally sensitive interventions.     

A review of smoking cessation interventions for smokers aged 50 and older

Objectives

Cigarette smoking poses substantial health risks at any age, but is particularly dangerous for older smokers, who are already at heightened risk for various health conditions. Studies suggest that older smokers are motivated to quit and succeed, but few of these have been randomized controlled trials. There is a need to systematically evaluate the research on effective interventions in older smokers.

Methods

We followed PRISMA guidelines in the development of this systematic review, which included randomized controlled trials of cessation interventions with smokers aged 50 or older.

Results

We found 740 unique titles matching specified search criteria; 13 met final eligibility criteria. Nearly all the cessation treatments combined counseling with other strategies. Eight studies provided smoking cessation medications. None of the studies used newer forms of technology such as web- or text-based interventions. Nine of the 13 studies reported a significant intervention effect at one or more time points, with three studies reporting sustained treatment effects at 12 mos or longer. In general, more intensive interventions and those with combined approaches including medications and follow-up counseling achieved the best outcomes.

Conclusion

The quit rates from these studies and the relative effectiveness of different intervention approaches are consistent with the general smoking cessation literature. However, in most studies, treatment effects were of short duration, and absolute quit rates were low, leaving the vast majority of older smokers at high risk for smoking-related health conditions. This systematic review suggests a need for additional research to design and test future interventions specifically tailored for older smokers.     

Characteristics of effective Internet-mediated interventions to change lifestyle in people aged 50 and older: a systematic review

Worldwide, the number of people aged 60 years and older steadily grows to a predicted 2 billion in 2050. Online interventions increasingly target lifestyle risk factors to promote healthy aging. The objective of this systematic review is to evaluate whether Internet mediated lifestyle interventions can successfully change lifestyle in people aged 50 and older. A PubMed search was conducted resulting in twelve articles, based on ten studies. The studies focused on physical activity, weight loss, nutrition, and diabetes. Nine studies used feasible interventions, with an average small to moderate effect size. The most important result is that there are multiple studies reporting positive lifestyle changes in an older population. On average, complex interventions, whether they present tailored or generic information, and online or offline comparison, are more effective than interventions with only one component. Internet mediated interventions hold great potential in implementing effective lifestyle programs, capable of reaching large populations of older persons at very low costs.     

A synthesis of meta-analytic evidence of behavioral interventions to reduce HIV/STIs

To identify the mode of delivery, communicator, and content dimensions that make STI/HIV prevention interventions most successful at increasing condom use/protected sex or reducing STI/HIV incidence. A literature search for published meta-analyses of STI/HIV prevention interventions yielded 37 meta-analyses that had statistically tested the moderating effects of the dimensions. Significant and non-significant moderators from the coded dimensions were extracted from each meta-analysis. The most consistently significant moderators included matching the gender or ethnicity of the communicator to the intervention recipients, group targeting or tailoring of the intervention, use of a theory to underpin intervention design, providing factual information, presenting arguments designed to change attitudes, and providing condom skills and intrapersonal skills training. The absence of significant effects for intervention duration and expert delivery are also notable. The success of HIV/STI prevention interventions may be enhanced not only by providing skills training and information designed to change attitudes, but also by ensuring that the content is tailored to the target group and delivered by individuals of the same gender and ethnicity as the recipients.     

Late middle-aged and older men living with HIV/AIDS: race differences in coping, social support, and psychological distress

Although AIDS mental health research has recently devoted more attention to the psychosocial needs of older adults living with human immunodeficiency virus (HIV) disease, studies of this population have typically combined older African-American and white participants into one large sample, thereby neglecting potential race differences. The current study examined race differences in stressor burden, ways of coping, social support, and psychological distress among late middle-aged and older men living with HIV/AIDS. Self-administered surveys were completed by 72 men living with HIV/AIDS in New York City and Milwaukee, WI (mean age = 53.4 years). Older African-American and white men experienced comparable levels of stress associated with AIDS-related discrimination, AIDS-related bereavement, financial dilemmas, lack of information and support, relationship difficulties, and domestic problems. However, in responses to these stressors, older African-American men more frequently engaged in adaptive coping strategies, such as greater positive reappraisal and a stronger resolve that their future would be better. Compared to their African-American counterparts, HIV-infected older white men reported elevated levels of depression, anxiety, interpersonal hostility, and somatization. African-American men also received more support from family members and were less likely to disclose their HIV serostatus to close friends. As AIDS becomes more common among older adults, mental health-interventions will increasingly be needed for this group. The development of intervention programs for this group should pay close attention to race-related differences in sociodemographic, psychosocial, and behavioral characteristics.     

Mathematical model for HIV/AIDS with complacency in a population with declining prevalence

An HIV/AIDS model incorporating complacency for the adult population is formulated. Complacency is assumed a function of number of AIDS cases in a community with an inverse relation. A method to find the equilibrium state of the model is given by proving a stated theorem. An example to illustrate use of the theorem is also given. Model analysis and simulations show that complacency resulting from dependence of HIV transmission on number of AIDS cases in a community leads to damped periodic oscillations in the number of infectives with oscillations more marked at lower rates of progression to AIDS. The implications of these results to public health with respect to monitoring the HIV/AIDS epidemic and widespread use of antiretroviral (ARV) drugs is discussed.     

Depression and social context: primary supporter relationship factors associated with depressive symptoms among a disadvantaged population with HIV/AIDS

Social support is associated with better health outcomes among chronically ill individuals, yet support receipt can be stressful. The study examined supporter relationship factors, among n=156 main‐supporter–HIV+support‐recipient dyads, associated with recipient's depression (CES‐D≥16). Results indicated that support recipient's depression was associated with a 3.6‐times higher odds of main supporters' depression, a 2.5‐times higher odds of supporters' being a friend or same‐generatin kin (versus partner or other kin), and a 3.7‐times higher odds of support recipients' financial reliance on the supporter. Support recipients' depression was positively associated with supporter–recipient conflict, and negatively associated with supporter–recipient communication. The model explained over half the deviance in recipients' depressive symptoms. Results suggest prevention interventions ought to target HIV seropositives and their main supporters and promote communication and conflict resolution skills. Such intervention approaches may alleviate their depression and promote sustained HIV‐related support, with potential implications to HIV treatment outcomes. © 2009 Wiley Periodicals, Inc.     

The impact of HIV/AIDS stigma on HIV counseling and testing in a high HIV prevalence population in Uganda

Background

Despite its importance in HIV/AIDS prevention and treatment, HIV/AIDS Counseling and Testing (HCT) is low in sub-Saharan Africa, where the disease continues to be a serious public health problem. This has in part been attributed to HIV/AIDS related stigma.

Objective

To assess the level of HIV/AIDS related stigma and its impact on uptake of HCT in a high HIV prevalence population in Uganda.

Methods

The paper used cross-sectional data on 135 men and 185 women in reproductive ages. Data were analyzed using the Pearson''s chi-square statistic and the random intercept binary logistic regression model to identify significant predictors of uptake of HCT.

Results

The result shows that only 18.4% of the respondents, most of them men expressed highly stigmatizing attitudes against PLHA and 59%, men and women alike, received HCT. Uptake of HCT was higher among men (OR=1.89, p<0.01) and women (OR=4.48, p <0.001) who expressed least stigmatizing attitudes. Secondary/higher education, work in the informal sector and being ever married were significant predictors of uptake of HCT. Compared to men, women aged 25–34, 35+ and with one sexual partner were more likely to have received HCT.

Conclusions

The low level of stigma, older age, higher level of education, being ever married and monogamous sexual relationships are significant predictors of increased uptake of HCT.     

Mathematical models for HIV transmission dynamics: tools for social and behavioral science research

HIV researchers have long appreciated the need to understand the social and behavioral determinants of HIV-related risk behavior, but the cumulative impact of individual behaviors on population-level HIV outcomes can be subtle and counterintuitive, and the methods for studying this are rarely part of a traditional social science or epidemiology training program. Mathematical models provide a way to examine the potential effects of the proximate biologic and behavioral determinants of HIV transmission dynamics, alone and in combination. The purpose of this article is to show how mathematical modeling studies have contributed to our understanding of the dynamics and disparities in the global spread of HIV. Our aims are to demonstrate the value that these analytic tools have for social and behavioral sciences in HIV prevention research, to identify gaps in the current literature, and to suggest directions for future research.     

HIV / AIDS in China: migrant population,drug injection responsible for increased transmission

By 2000, China will have 1.2 million people infected with HIV and 33,000 people with AIDS. While HIV infection has been reported from almost all provinces and occupational groups in the country, HIV prevalence is highest among IV drug users in Yunnan province. The major source of infection elsewhere in China is through the receipt of tainted blood products and heterosexual intercourse. A National AIDS Committee was formed in October 1986 to advise the government on AIDS policy, and since 1990 to coordinate all AIDS prevention activities. The National Strategies Plan for AIDS/STD Prevention in China during 1996-2000 was prepared in 1995. China's in-country migrant labor population may become the most vulnerable to HIV infection. There are currently about 120 million migrant workers in China, of whom about half are registered, nonpermanent residents working in the fastest developing regions. The open nature of China's economy relative to recent past decades has made it difficult to monitor and control internal migration. Floating populations are the most difficult to reach with preventive health education and they tend to be deprived of access of health care. 61.4% of the migrant population is male and 40% are aged 20-24 years. China's traditional trade routes may be a factor in HIV infection. HIV/AIDS epidemiology, the synergy of STDs and AIDS in China, the international partnership in HIV/AIDS prevention in China, the role of international nongovernmental organizations in China, Hong Kong's contribution to AIDS prevention in China, awareness of the problems associated with HIV infection in China, and the challenges for AIDS-related work in China are discussed.     

Implementation science for the prevention and treatment of HIV/AIDS

Implementation science is the scientific study of methods to promote the integration of research findings and evidence-based interventions into health care policy and practice and hence to improve the quality and effectiveness of health services and care. Implementation science is distinguished from monitoring and evaluation by its emphasis on the use of the scientific method. The origins of implementation science include operations research, industrial engineering, and management science. Today, implementation science encompasses a broader range of methods and skills including decision science and operations research, health systems research, health outcomes research, health and behavioral economics, epidemiology, statistics, organization and management science, finance, policy analysis, anthropology, sociology, and ethics. Examples of implementation science research are presented for HIV prevention (prevention of mother-to-child transmission of HIV, male circumcision) and HIV and drug use (syringe distribution, treating drug users with antiretroviral therapy and opioid substitution therapy). For implementation science to become an established field in HIV/AIDS research, there needs to be better coordination between funders of research and funders of program delivery and greater consensus on scientific research approaches and standards of evidence.