The white paper includes recommendations regarding:

• Removing the “age-cap” of age 64 for recommended routine HIV testing
• Counting prescriptions paid through AIDS Drugs Assistance Programs as Medicare Part D “true out-of-pocket costs” to enable older people with HIV to move past the Medicare “donut hole” and become eligible for Medicare Part D catastrophic coverage
• Increasing federal funding for basic research into the medical and mental health needs of older adults living with HIV;
• Developing a Standards of Care specific to older persons with HIV
• Prevention and education messaging to adults age 50 and over
• Integrating HIV and aging services networks and provide the tools necessary to document, address and resolve complaints of discrimination on the basis of HIV status, sexual orientation and/or gender identity/expression

SAGE developed this paper in collaboration with members of the National LGBT Aging Roundtable who focus on HIV work.  Partners included ACRIA, Gay Men’s Health Crisis, GRIOT Circle, the National Association on HIV Over Fifty, the National Gay & Lesbian Task Force, SAGE of Metro St. Louis, and the Transgender Aging Network.  We also asked our colleagues at AIDS Action and the San Francisco AIDS Foundation to review the work.

For more information on SAGE, visit sageusa.org

Karen Taylor, Director of Community Advocacy & Capacity-Building, SAGE

Many organizations have begun identifying solutions. Some offer counseling, or educational services for the client and their families to gain skills needed to cope with the challenges they face. Others attempt to integrate health care services with exercise and social activities. The Program of All-inclusive Care for the Elderly (PACE) brings  elderly patients with multiple chronic diseases to local day centers three to four days a week. Participants interact with doctors, aides and physical therapists, while participating in activities, recreation, and social services.

A key factor in management programs for most chronic diseases is the family; however, for most older adults with HIV there is an absence of family support. ACRIA’s own ROAH  study illustrates this in its finding that over 70% of this population lives alone, and less than 20% have a spouse or partner. They lack the functional social network from which caregiving support is derived. The older adult with HIV is stigmatized if not ostracized, socially isolated, and demonstrates high rates of untreated depression, as reflected in high levels of loneliness. Without family support these older adults with HIV must either find support from within the larger community or be relegated to further isolation—for example in costly long-term health care facilities.

This is the next challenge of the HIV epidemic: How will we as a community care for older adults with HIV?

In the ROAH study of older adults with HIV in New York City, approximately two-thirds reported clinically significant levels of depressive symptoms. This level of depression among older adults with HIV far exceeds other groups with chronic or acute health problems, yet these individuals are engaged with our health care system; most see a physician 3 to 4 times per year related to ARV treatment. Anecdotally, we hear that many physicians are aware of this problem, but the resources are not available to do anything about it. We also hear from clients that they have recognized their depression, sought treatment, but discontinued it because they needed something more in the way of therapy than one more prescription from a psychiatrist.

In response to this situation, ACRIA initiated the Mapplethorpe-Haring depression intervention project in 2008. This project was based on the MacArthur intervention model which is brilliant due to its simplicity; in addition to the usual course of care for depression, the client receives a brief support telephone call once per week to check-in and see how things are going. We later expanded this model (renamed the Mapplethorpe-Haring Model) to include a therapy group based on problem-solving and self-affirmation in response to the complex issues that these clients presented during screening and intake.  Phase I was highly successful with a significant reduction in depression in our clients. During Phase II, we plan to verify and document this treatment model so that it can be widely used by ASOs and CBOs serving this population.

There are costs associated with untreated depression among these older adults. For example, people with HIV who are depressed are less likely to adhere to their ARV regimens, leading to a greater chance of viral mutations and treatment failure, as well as a greater likelihood of infecting others if engaging in risky behaviors. Part of our national AIDS strategy needs to address depression and other mental health problems among older adults with HIV – what should that strategy be?