Due to the changing landscape of HIV, older adults are living with HIV at rates higher than ever before. In 2018, the prevalence of diagnosed HIV infection in the United States (U.S.) was 374.6 per 100,000 population with an increased number of estimated cases affecting older Americans over the age of 50.1 Even though HIV is no longer a death sentence due to the development of effective antiretroviral therapy (ART) and other HIV focused therapeutics, significant disparities in treatment outcomes persist among certain demographics. In general, HIV continues to not only affect racial/ethnic minorities at higher rates, but also gay, bisexual, and men who have sex with men (MSM) compared to their cis-gender heterosexual white counterparts.2 Therefore, research must look to the intersections of age, race, ethnicity, and sexual identity in developing interventions that may best support those most at risk for poor HIV-related treatment outcomes.
Significantly more people with HIV (PWH) are living into older adulthood demonstrating a growing need for HIV-focused research and treatment examined through an aging lens. According to 2018 CDC data, more than half of PWH in the U.S. are over the age of 50 years1 with predictions that by the start of 2021 almost 70% of PWH in the United States will be at least 50 years old.3 Older adults are often diagnosed with HIV much later (~ 4.5 years after infection) indicating more advanced disease progression associated with the epidemic among this age group.1 Additionally, for PWH in the United States aged 55 and above, while 90% knew their HIV status, only 64% were virally suppressed and barely more than half (57%) were actively engaged in care, suggesting that the “90-90-90” goals towards ending the HIV epidemic4 are currently out of reach among older adults with HIV (OAWH).1
Latinos have been disproportionately affected by HIV since the origins of the epidemic, and that increased vulnerability has deepened over time. Despite representing less than 20% of the entire U.S. population, Latinos make up 27% of new HIV diagnoses and account for over 20% of the national prevalence.5 More specifically, Latino sexual minority men (LSMM) are responsible for almost 25% of new HIV infections among all gay, bisexual, and MSM identified individuals2 despite Latino men making up less than 9% of the entire U.S. population.6 These disparities persist beyond just HIV incidence with Latino identified PWH facing additional challenges with their HIV treatment care due to suboptimal rates of viral suppression7,8 and ART adherence9 compared to their non-Latino SMM peers.
Unsurprisingly, these racial/ethnic disparities become significantly more observable among older adults. Older Latinos in the U.S. are slightly more than 5 times more likely to acquire HIV10 and are more likely to have an AIDS diagnosis, detectable viral load, and poorer treatment adherence compared to their age-matched white non-Latino counterparts.11,12 Additionally, older Latinos seem to exhibit mild to moderate cognitive impairment in learning, memory, and processing speed compared to their non-Latino white peers.12,13 It is likely that these intersecting social determinants (i.e. age, race/ethnicity, sexual identity) will continue as the HIV population ages and that many of these poor health outcomes will be felt most intensely by older Latinos.
Older Latinos with HIV experience various physical health disparities due to their intersecting minority status that must be considered. In general, OAWH face increased rates of age-related comorbidities due to a phenomenon called accelerated aging.14,15 Data from a large observational cohort study of OAWH reported that over 77% of participants reported suffering from two or more health comorbidities in addition to HIV16 with the average number of physical comorbidities per participants landing at three.17 In particular, older HIV-positive Latino individuals are disproportionately affected with cardiometabolic diseases including metabolic syndrome (MetS), a precursor to diabetes, as well as cardiometabolic risk factors such as obesity and hypertension compared to their non-Latino older white peers.18,19,20 Moreover, older Latinos with HIV are more likely to be sedentary and not as actively engaged in pursuing changes in their physical activity compared to their non-Latino white counterparts.21 Despite evidence of the “Hispanic Paradox” 22, this lack of physical activity in combination with possible issues connected to ART medication and Hepatitis-C co-infection make older Latino adults with HIV more likely to suffer from other complicating physical conditions like nonalcoholic fatty liver disease23,24 and cardiovascular issues compared to their non-Latino white counterparts.
Older Latinos with HIV face elevated rates of mental health concerns in addition to these physical comorbidities. More generally, OAWH have documented rates of major depressive episodes anywhere between 18 and 52%17,26,27, significantly higher than the 1–8% documented rates of depression among older adults in the general population.28 Rates of social isolation in the general aging public (60 years or older) are estimated to be anywhere between 33% and 50%29 with evidence suggesting that OAWH face social isolation more often than their age matched peers in the general population.30,31 Similarly, there is strong evidence to suggest that loneliness exponentially increases with age and one could predict OAWH bear even a greater amount of loneliness due to reduced social networks and ostracism.32,33 Additionally, loneliness and social isolation have been correlated with levels of morbidity and mortality comparable to more established biopsychosocial risk factors like obesity, sedentary behavior, smoking, and hypertension.29,34,35
For OAWH, one of the biggest contributing factors to loneliness and social isolation is that of co-occurring stigma. While exact estimates of HIV stigma and age-related stigma in the U.S. are hard to calculate, OAWH must often navigate the dueling stigmas of HIV stigma, ageism, and stigma resulting from other possible marginalized identities.36–38 It is possible that rates of stigma and loneliness seem to skyrocket in OAWH due to the increased likelihood that OAWH live along and have limited and often inconsistent social networks.26,38 OAWH can face ostracism from the larger LGBTQ + community and stigma due to the intersection of their age and HIV status compared to their non-infected peers which may in turn contribute to the increased levels of depression among this already vulnerable population.39 Additionally, since familism and social cohesion are strong hallmarks of Latino culture,40,41 Latino OAWH may experience the harmful effects of co-morbid stigma and social isolation more intensely than their non-Latino HIV-positive peers due to societal expectation that they be more connected to family as they age; however, more research must be conducted to determine the veracity of such a hypothesis.
As outlined above, compounded health disparities place older Latinos with HIV at particularly high risk for diminished quality of life due to physical and mental health morbidity. These data underscore the public health importance of increased efforts to address the multiplicative and unequal burden of HIV, MetS, and diabetes shouldered by older Latinos. Therefore, based on this gap in the literature, there is a compelling need to develop and disseminate interventions that promote healthy living, combat social isolation, and improve HIV-related health outcomes among older Latinos with HIV. Since this is a pilot study, researchers are focused on establishing feasibility and acceptability of a potential intervention rather than testing specific hypotheses. Also, in accordance with recommendations from biostatistical workgroups funded by NIH,42 this pilot study is not powered to test a hypothesis. Rather, this pilot study serves as an initial step in establishing feasibility and acceptability of an innovative application of an already established health promotion intervention titled HOLA.43 The specific aims of this pilot study are:
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To evaluate the feasibility of recruitment, assessment procedures, retention, acceptability, and implementation of HOLA in a sample of midlife and older Latinos with HIV.
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To identify modifications needed in the design of a larger, confirmatory randomized controlled trial.
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To explore changes in cardiometabolic risk factors (waist circumference, dyslipidemia, hypertension, and glucose), psychosocial functioning (depression and anxiety severity, social support), and health-related quality of life in a sample of midlife and older Latinos with HIV enrolled in the HOLA health promotion intervention.