Using Focus Group Feedback to Identify Patient-Centered Initiatives for Older Persons with HIV.

Objectives: This study assessed how few community-based programs target older people living with HIV.Methods: We conducted four focus groups comprised of people 50 and older with HIV (N = 32; gay/bisexual men, heterosexual men, women, and Spanish-speakers) to inform HIV program development by exploring the services in which participants were actively involved, along with the services they wanted to receive.Results: Using inductive thematic qualitative analysis, four themes were identified pertaining to program development: (a) types of currently utilized HIV service organizations; (b) dissatisfaction with HIV programming and services; (c) participants' preferred programming, courses, groups, or activities; and (d) desire to serve as peer mentors.Conclusions: Results highlight the need for community-based organizations to address social engagement and isolation among older people living with HIV.Clinical implications: These findings exemplify the need for programs to be specifically designed for OPH, and created with the primary goals of socialization and helping develop social support networks.

Sexual Health Among Lesbian, Gay, Bisexual, and Heterosexual Older Adults: An Exploratory Analysis.

Objectives: A significant gap in our knowledge concerns sexual health among the older lesbian, gay, and bisexual (LGB) population.Methods: We compared a community-based sample of self-identified LGB older adults (n = 128) with population-based samples of behaviorally-defined LGB older adults (i.e., reporting same-sex experiences) (n = 112) and behaviorally-defined older heterosexuals (i.e., reporting no same-sex experiences) (n = 2,893) from the National Social Life, Health and Aging Project (NSHAP). Differences in sexual activity and sexual problems were examined.Results: Older LGB adults were as likely to remain sexually active as older heterosexuals. Gay and bisexual men were more likely than heterosexual men to report some sexual problems. Regardless of sexual orientation, older adults rarely had their sexual health needs addressed in healthcare settings.Conclusions: Results highlight the need for more research on LGB older adult sexual health.Clinical Implications: The lack of attention to LGB older adults' sexual health in healthcare settings may be exacerbated by ageism and heterosexism, leading these individuals to avoid disclosing their sexual orientations and avoid conversations about sexuality. Mental health practitioners require education on associations between sexual health and mental health, and how sexual health problems may contribute to mental health concerns in vulnerable populations like older LGB adults.

Aging gay male veterans: a community-based study on their health and psychosocial needs.

Lesbian, gay, and bisexual persons have served in the military throughout history despite military policies that necessitated concealment of their sexual orientation. This secondary data analysis of research from a community-based study of sexual and gender minority (SGM) older adults sought to explore the unique needs of this growing "out" population and identify the future program, policy, and research goals. The sampling population for this study was drawn from a community-based study conducted initially by researchers from the ACRIA center. The SGM veterans in this pilot study were recruited from the Center on Halstead, the largest SGM community-based center in the Midwest. Twenty-six veterans' self-identified as gay men. Considering the minority stress model, data from this study identified a group of men with less social support - either formal or informal, less housing and economic security, and low service utilization. Interestingly, this group also self-reported as having a more positive mental and physical health outlook than previous research with this population. This study also identified a clear need for education, more extensive population-based mixed methods studies to help understand fully the needs of this previously "invisible" population of older military veterans.

The Intersectionality of Stigmas among Key Populations of Older Adults Affected by HIV: a Thematic Analysis.

OBJECTIVES: The present study examined the intersectionality of stigma across varying groups of older persons living with HIV (PWH). METHODS: Four focus groups of older PWH (gay/bisexual men, heterosexual men, heterosexual and bisexualwomen, and Spanish-speaking) were audio-recorded and transcribed. Inductive thematic text analysis was used to identify qualitative themes. RESULTS: Five major themes emerged from the data: 1) disclosure of HIV status; 2) types of stigma experienced; 3) discrimination experienced; 4) other outcomes associated with experiencing stigma; and 5) influence of aging on social isolation experienced due to stigma. Findings indicate women did not suffer from the intersection of stigmas. Other groups suffered from the intersection of stigma due to HIV status and age (gay/bisexual males); HIV status and perceived stigma of sexual orientation or drug use (heterosexual males); and HIV status and culture/ethnicity (Spanish-speaking). CONCLUSIONS: Results indicate that many at-risk groups, including heterosexual men, homosexual men, and Spanish-speaking individuals, experience an intersection of stigma between aging and their sexuality, HIV status, or real or perceived drug use. CLINICAL IMPLICATIONS: Results highlight the need for HIV support, especially social support, to address intersection of stigmas for unique groups of individuals disproportionately affected by HIV.

Addressing sexual health in geriatrics education.

Adults remain sexually active well into later life, but few report discussing sexual health with a physician after age 50. The authors explored how geriatrics education might better address sexual health in the context of a psychosocial conference for geriatrics fellows, program directors, and faculty comprising an informational plenary, which included a skills-building presentation on taking sexual histories, and a program director/faculty roundtable. Although informed about older adult sexual health, knowledge scores of geriatrics fellows increased following the plenary. Fellows reported inconsistent sexual history taking with older adults and noted patient differences in age and gender as barriers. The roundtable discussion highlighted several barriers to inclusion of sexual health content in geriatrics curricula including competing competencies, lack of educational materials, and discomfort with this topic on the part of faculty. Implications of these findings for geriatrics training and education programs and suggestions for improving this domain of geriatrics education are discussed.

Training senior service providers about HIV and aging: Evaluation of a multiyear, multicity initiative.

The Centers for Disease Control and Prevention estimate that in 2015, one half of all people living with HIV in the United States will be older than age 50. Older adults remain sexually active, and 16% of all new HIV diagnoses occur in adults age 50 and older. However, older adults rarely see themselves at risk for HIV/AIDS, and physicians are frequently reluctant to discuss sex. To address the issue of aging and HIV, ACRIA created its National Older Adults with HIV (NOAH) technical assistance and capacity-building program. NOAH targets aging and HIV providers that serve older adults at risk for or living with HIV. Program goals include increasing knowledge, reducing stigma, and creating partnerships between senior service providers (SSPs) and HIV service providers. In its first 4 years, NOAH training was provided to 150 organizations in eight cities across the United States, reaching 332 agency staff. Outcome evaluation found significant increases in knowledge about HIV and aging, and programmatic impact with regard to integration of older adults and HIV information in participating agencies' activities. Ongoing issues included recruiting SSPs and difficulties in reaching agencies that participated for short- and long-term follow-up. Implications for workforce development are discussed.

Substance use and sexual risk differences among older bisexual and gay men with HIV.

Bisexual and gay men are disproportionately affected by HIV/AIDS. Research typically combines these groups into the category of men who have sex with men, and little is known about between-group differences. HIV-positive populations are aging and have high rates of substance use compared to non-infected peers, while substance use among older adults has increased and is associated with unprotected intercourse. Among a sample of 239 HIV-positive bisexual and gay men aged 50 and older, bisexual men were more likely to report cigarette, cocaine, crack, and heroin use compared with gay men. However, bisexual men were less likely to use crystal meth, club drugs, poppers (nitrate inhalers), and erectile dysfunction (ED) medications compared to gay men. While bisexual men reported lower rates of unprotected sex, logistic regression analysis found that current use of poppers and ED drugs, which were higher among gay men, explained this difference. Implications for education and prevention programs are discussed.

Correlates of Subjective Cognitive Decline in Lesbian, Gay, Bisexual, and Transgender Older Adults.

BACKGROUND: Little is known about subjective cognitive decline (SCD) in lesbian, gay, bisexual, and transgender (LGBT) older adults. OBJECTIVES: To examine SCD and its association with dementia risk factors, other physical and psychosocial health factors in LGBT older adults. METHODS: A cross-sectional study of SCD was conducted with LGBT older adults, aged 50 and older (n = 210). SCD was categorized based on endorsement of memory problems and one other cognitive domain. Hierarchical logistic regression examined the associations between demographic factors, dementia risk factors, other health and psychosocial factors, and SCD. RESULTS: Nearly 25% of LGBT older adults were classified as having SCD. LGBT older adults who were people of color (OR = 2.5; 95% CI = 1.1- 7.8), depressed (OR = 2.9; 95% CI = 1.3- 6.9), or reported having functional impairment (OR = 2.6; 95% CI = 1.1- 6.5) were significantly more likely to be classified as having SCD (Nagelkerke pseudo R2 = 0.27). CONCLUSION: Depression and functional impairment should be considered when screening LGBT older adults for cognitive impairment and dementia. Future research on the cognitive impairment and dementia risk in LGBT older adults is needed.

Social Support Systems and Social Network Characteristics of Older Adults with HIV.

Social networks of older adults with HIV have been characterized as fragile, with a greater reliance on friends as compared to family. However, we know little about the subgroup differences in the social network constellations of this population, how such characteristics are related to social support resources, and their relationship with psychosocial well-being. We developed a typology of social networks of older HIV-positive adults and examined if they would be related to receipt of informal assistance, perceptions of support sufficiency, and psychosocial well-being. Data were obtained from Research on Older Adults with HIV (n = 914). Participants were 50 years and older, HIV positive, and diverse in terms of race/ethnicity, gender, and sexual orientation. Cluster analysis identified Isolated, Friend-centered, and Integrated social network types. The Isolated reported significantly lower levels of assistance, lower perceptions of support availability and adequacy, greater stigma and psychological distress, and lower well-being compared to their peers. While friends dominate many social networks in this population, a more nuanced interpretation is needed; many have no friends and a substantial proportion receive significant family support. Those with Isolated network types will likely need to access a high volume of community-based services as they age as they lack informal support resources.

The Impact of Comprehensive Case Management on HIV Client Outcomes.

In 1990, New York State instituted Comprehensive Medicaid Case Management, also known as Target Case Management (TCM), for people dealing with multiple comorbid conditions, including HIV. The goal of TCM is to assist clients in navigating the health care system to increase care engagement and treatment adherence for individuals with complex needs. HIV-positive individuals engaged in care are more likely to be virally suppressed, improving clinical outcomes and decreasing chances of HIV transmission. The purpose of this study was to understand the impact of TCM management on outcomes for people with HIV. Data were obtained from Amida Care, which operates not-for-profit managed care Medicaid and Medicare Special Needs Plans (SNPs) for HIV clients. Changes in clinical, cost, as well as medical and pharmacy utilization data among TCM clients were examined between January 2011 through September 2012 from the start of case management enrollment through the end of the study period (i.e., up to 6 months after disenrollment). Additionally, CD4 counts were compared between Amida Care TCM clients and non-TCM clients. Notable findings include increased CD4 counts for TCM clients over the one-year study period, achieving parity with non-TCM clients (i.e., Mean CD4 count > 500). When looking exclusively at TCM clients, there were increases in medication costs over time, which were concomitant with increased care engagement. Current findings demonstrate that TCM is able to achieve its goals of improving care engagement and treatment adherence. Subsequent policy changes resulting from the Affordable Care Act and the New York State Medicaid Redesign have made the Health Home the administrator of TCM services. Government entities charged with securing and managing TCM and care coordination for people with HIV should provide thoughtful and reasonable guidance and oversight in order to maintain optimal clinical outcomes for TCM clients and reduce the transmission of HIV.

Social care networks and older LGBT adults: challenges for the future.

Research on service needs among older adults rarely addresses the special circumstances of lesbian, gay, bisexual, and transgender (LGBT) individuals, such as their reliance on friend-centered social networks or the experience of discrimination from service providers. Limited data suggests that older LGBT adults underutilize health and social services that are important in maintaining independence and quality of life. This study explored the social care networks of this population using a mixed-methods approach. Data were obtained from 210 LGBT older adults. The average age was 60 years, and 71% were men, 24% were women, and 5% were transgender or intersex. One-third was Black, and 62% were Caucasian. Quantitative assessments found high levels of morbidity and friend-centered support networks. Need for and use of services was frequently reported. Content analysis revealed unmet needs for basic supports, including housing, economic supports, and help with entitlements. Limited opportunities for socialization were strongly expressed, particularly among older lesbians. Implications for senior programs and policies are discussed.

Service utilization among older adults with HIV: the joint association of sexual identity and gender.

This study examines the association of sexual identity and gender among older clients with HIV at an AIDS service organization using the Andersen Model. Data confirm those aging with HIV exhibit high rates of age-associated illnesses 10 to 20 years before expected. They have fragile social networks that cannot supply the informal supports needed. This aging population will need to increasingly access community-based services. Sexual identity and gender were weak covariates of service utilization. Although heterosexual men used more services, utilization was largely predicted by service needs and the use of case management. Implications for service delivery and policy are discussed.