National Centre in HIV Social Research

Growing old or growing “up” with HIV

Dr Limin Mao, NCHSR

Older generation of PLHIV

Model estimated changing demographic of PLHIV

Mean age of PLHIV to be increased at a rate of 0.49 years per annum

Expected proportions of PLHIV 55 years and above to be increased from

25.3% in 2010 to 44.2% by 2020

While the metropolitan areas will still have the highest HIV prevalence, other

areas (including rural ones) will have greater percentage growth 2010-2020

Jasson & Wilson (2012) Plos One 7: e38334

Blessings from HIV antiretroviral treatment?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1985 1995 2002 2005 2013 2020

2.7% 6.7% 13.6% 18.3%

30.1% 43.2%

>=55 years

26-54 years

<25 years

Before ART Start of the HIV

epidemic Before cART

Jasson & Wilson (2012) Plos One 7: e38334

Ageing gay men in Sydney:

Gay Community Periodic Surveys

10.2 9.1 10.4 12.2 12.9 13.7 14.5

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007 2008 2009 2010

under 25 25-29 30-39 40-49 50 and over

Increasing demand for HIV GP services but decreasing

supply

HIV s100 GP prescriber workforce:

Proportions treating per week (increasing workload) based on a GP survey:

10 or more patients stable: 38.8% in 2007 to 42.6% in 2009

2-9 HIV+ patients increased: 36.5% in 2007 to 49.1% in 2009

0-1 HIV+ patients decreased: 24.7% in 2007 to 8.3% in 2009

Estimated demand vs supply-services with at least one s100 GP prescriber:

Metro areas: estimated number of PLHIV increased by 12.5% but such services

decreased from 60 in 2007 to 55 in 2010

Rural and remote areas: estimated number of PLHIV increase by 16.5% but such

services decreased from 31 in 2007 to 25 in 2010.

Mallitt et al., (2012) Sexual Health (published online 19th Nov.)

Distribution of sexual health services in 2007:

state variations

0

10

20

30

40

50

60

70

80

90

100

NSW Vic QLD SA WA TAS ACT NT

Gay friendly GP

Hospital units

SHC

39

100

38 42

6 6 7 8

Pell et al., (2008) Sexual Health, 5: 161-8

Distribution of sexual health services in 2007:

Urban vs rural/regional

0

10

20

30

40

50

60

70

80

90

100

NSW Vic QLD SA WA TAS ACT NT

Rural/regional

Urban

39

100

38 42

6 6 7 8

Pell et al., (2008) Sexual Health, 5: 161-8

Packages of care for PLHIV: (Models of Access and

Clinical Service Delivery 2009)

Clinical & allied health care Referral to non-clinical, “formal” care

(housing, financial support)

Specific groups:

Those with highly complex needs

ATSI

CALD

? Informal care by family, partners, friends &

community (public or private)

Right time,

right place,

by the right team

Availability, access & preference: the ageing factor

Clinical & allied health care Referral to non-clinical, “formal” care

(housing, financial support)

Specific groups:

Those with highly complex needs

ATSI

CALD

Informal care by family, partners, friends &

community (public or private)

Right time,

right place,

by the right team

Chronic co-morbidies: CVD,

diabetes, depression,

dementia, AoD, ageing

workforce too!

Disability pension, re-engaging with

the work force & volunteering,

unstable housing

Fear of disclosure,

discrimination, non-nuclear

family, living alone, peer

support, affordibility

Cultural and sexual expressions,

changing needs,

interdependence & mixing

GLBT in aged care services

Sexuality & lifestyle

Safety & Quality of

formal aged care

HIV infection &

management Chronic illness & mental

wellbeing

Barrett (2008) report “My people…”

HIV and ageing: important knowledge gaps

• Promotion of healthy lifestyles and reducing co-

morbidity: stop smoking; control blood pressure,

decrease alcohol consumption, lose weight,

exercise, poly-pharmacy, substance use, ART

adherence

• Neurocognitive function & mental health

• HIV prevention: safer sex, new sexual partners,

sexual dysfunction

High et al. (2012) JAIDS, 60: s1-s18

HIV and ageing: important knowledge gaps

• Successful ageing: resilience

• Stigma in relation to networks and care giving

• Community resources: the role of informal

support, nonmedical community-based services,

training service providers of GLBT issues, faith-

based orgs, paid helpers etc

High et al. (2012) JAIDS, 60: s1-s18

HIV and ageing: important knowledge gaps

• Women

– Menopausal transition and beyond: sex hormones

– Bone health

– Gender roles: prioritising care for others over self

care, silencing the needs of the self to avoid relational

conflict and loss, subordinating to male partners

– Immigrants with a traumatic experience in the past

High et al. (2012) JAIDS, 60: s1-s18

Socially constructed ongoing ageing process: the

illusion of “successful ageing”

• Pension & income earnings (financial)

• Health care (illness & access)

• Structural deprivation: people with complex needs but often having low trust towards the system

Cultural/religious

beliefs & norms Expectations &

Perceived QoL

Interpersonal interactions:

personal support networks,

professional carers, HCW

Social, structural &

physical constraints

Fox (2005) Sociology 39: 481-98

Independence &

interdependence

Where to from here?

• What are the key issues we already know?

High rates of current Major Depressive Disorder

(NHMRC HIV & Depression project 2007)

High co-existence: MDD & male sexual problems

(NHMRC HIV & Depression project 2007)

Most common: ED or loss of libido

GCPS: UAIC rates doubled in 15 years

0

100

200

300

400

500

600

700

800

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

HIV- gay men

HIV+ gay men

Where to from here?

• A doom & gloom picture? – Infectious diseases (HIV and other STIs) and safer

sex

– HIV treatment initiation, disease monitoring and lifelong adherence

– HIV-related co-morbidities, pre-mature ageing and poly-pharmacy

– Alcohol, smoking and recreational drug use

– Depression, Sexual dysfunction

– Living alone and lack of social support from significant others or community

Where to from here?

• How to involve aging GLBT population who are

living with HIV?

Patient, consumer & citizen: expand beyond self-

management

Patient following a self-management plan

Increased self-efficacy and enhanced skills

Compliance

(Medicine, Nursing, Cognitive Psychology)

Greenhalgh (2009) BMJ 338: 629-31

Patient, consumer & citizen: expand beyond self-

management

Copying with chronic illness

Coherent self (disease narratives & meaning

making), adaptive and pragmatic response

Informed choices, resilience, understanding of the

lived experiences of illness

(Sociology of health & illness)

Greenhalgh (2009) BMJ 338: 629-31

Patient, consumer & citizen: expand beyond self-

management

A holistic, personalised care plan drawing on available community resources

Engaged citizen, aligned with prevailing norms and values, seeking to develop health and community services

Emergence of new structures and opportunities for supporting healthy living and managing illness

(Social Ecology)

Greenhalgh (2009) BMJ 338: 629-31

Patient, consumer & citizen: expand beyond self-

management

Recognising and challenging structural barriers to good health (poverty, discrimination, social exclusion)

Engaged citizen, opposed to prevailing norms and values, seeking social justice

Fundamental change in the social and political structures that constrain individual action and underpin health inequalities

(Critical Sociology)

Greenhalgh (2009) BMJ 338: 629-31

A comprehensive, co-ordinated, people-centred,

evidence-based care model:

Patient, consumer & citizen

Greenhalgh (2009) BMJ 338: 629-31