Assistant Professor of Medicine
Harvard Medical School
Infectious Disease Divisions
Massachusetts General Hospital
Brigham and Women's Hospital
Bisola Ojikutu, MD, MPH, has no relevant conflicts of interest to report.
Nearly one half of people living with HIV (PWH) are now aged 50 years or older in the United States. Care for older PWH can be quite challenging due to the comorbidities and social issues that come with aging and HIV infection. Furthermore, as an HIV specialist whose patients are predominantly older PWH, I have witnessed the difficulties encountered by older PWH in accessing and being retained in care.
HealthHIV’s Inaugural State of Aging With HIV National Survey™ was conducted in 2019 to better understand the challenges faced by older PWH. The online survey recruited 831 PWH aged 50 years or older, with most participants identifying as white, male, gay, and low income. Below, I share my perspective on 3 key barriers to care in older PWH that were identified by the survey, along with how we can better meet the needs of this population.
One key finding was that 56% of participants reported being diagnosed with depression, but only 36% had seen a mental healthcare provider (HCP). I have seen how depression in older PWH is exacerbated by isolation and HIV status. Sadly, I am unsurprised by the low rate of older PWH seeing a mental HCP, given that the few psychologists, psychiatrists, and social workers trained to work with diverse patient populations are often not easily accessible. Furthermore, older PWH may feel a stronger sense of the stigma often associated with engaging in mental healthcare, which inhibits them from seeking care and from taking psychiatric medications. These barriers could be reduced by improving access to culturally appropriate, sex-positive, gender-affirming mental HCPs.
Second, only 35% of participants had seen a case manager. This is concerning because many older PWH are impacted by social determinants of health— such as housing and food insecurity, difficulty accessing ART and other medications, and/or transportation challenges—that need to be addressed in addition to their complex HIV and non-HIV related medical issues. However, due to time constraints, the social determinants of health are often not addressed by the HCP.
As the director of the Community Engaged Research Program through Harvard University’s Center for AIDS Research, I have observed that HCPs in academic centers are often unaware of community resources that can help their patients cope with social determinants of health. By referring our older PWH to case managers and community navigators, we can help link our patients to these community-based resources.
Finally, many older PWH have encountered stigma (52%), ageism (26%), and homophobia (25%) in the healthcare setting. It was unclear whether the survey asked about racism, but I think that is another bias that individuals often encounter when seeking care.
Because much of my work focuses on racial and ethnic inequalities in HIV healthcare, I found these results both unsurprising and disturbing. HCPs generally do not undergo mandatory training in overcoming their implicit and unconscious biases. Such biases can be off-putting and result in losing patients from care. We should require that antibias training be a component of trainee education and continuing education to enable older PWH to feel more comfortable accessing care and making appointments.
Overall, these barriers culminate in lower retention in care, which is particularly important for older individuals with HIV because they are more likely to have multiple comorbidities and longer treatment histories that require more complex management approaches. The results of HealthHIV’s Inaugural State of Aging With HIV National Survey™ highlight the need for improved training and education for HCPs to remove these and other barriers faced by older PWH to better serve our patients.
What challenges have you observed when engaging and retaining older PWH in care? Please answer the polling question and share your thoughts in the comments box. Click here to review HealthHIV’s Inaugural State of Aging With HIV National Survey™ report in its entirety to better understand the demographic, medical, and cultural characteristics of aging individuals with HIV in the United States.
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