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Living longer with HIV associated with depression

Longer time living with diagnosed HIV infection is strongly associated with depression, anxiety and poor quality of life, according to UK research. Older age in itself was not associated with symptoms of distress or poor mental health but did have an association with lower physical functioning.

“The association between longer time with diagnosed HIV infection and poorer health is likely to be related to earlier calendar time of diagnosis: having been diagnosed at a time when HIV prognosis was poor, treatments were less effective or complex, HIV-related stigma was greater, and companions and supportive networks may have been lost,” suggest the authors led by Jennifer A McGowan, research department of infection and population health, University College London. “It may also be related to increased time living with a chronic disease and its health and social implications, younger age at HIV diagnosis, the effect of prolonged HIV treatment, or the effect of longer time with untreated HIV infection.”

The investigators want their findings to be taken into account in the design of services for HIV-positive adults as they age.

Improvements in treatment and care mean that many, if not most, HIV-positive people in the UK now have a near-normal or normal life expectancy. The proportion of people with diagnosed HIV infection in the UK aged 50 years or older has doubled in the last decade.

Diseases normally associated with older age are now a leading cause of serious illness and death in people with HIV. However, few studies have examined the effect of older age on the overall wellbeing of people with HIV.

Investigators from the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study designed a questionnaire to measure the effect of age on the prevalence of symptoms causing distress; the prevalence of symptoms of anxiety and depression; and the prevalence of health-related functional problems among people receiving care at nine UK clinics. The questionnaire also asked about the time since HIV diagnosis and demographic factors.

Recruitment took place between 2011 and 2012 and the study population comprised 3,258 people – 69% of participants were in the men who have sex with men (MSM) risk group, 11% were heterosexual men and 20% were women. The mean age was 45 years and 28% were aged 50 years or older. Just under half (45%) the participants had been living with diagnosed HIV infection for ten or more years. The majority (68%) were white and a fifth were black African. A substantial proportion (40%) had been to university. Just over half the sample was in employment, but 13% were not working because of illness/disability, 18% were unemployed and 6% were retired.

Overall, 86% of individuals were on antiretroviral therapy (ART), 76% had an undetectable viral load and 81% had a CD4 count above 350 cells/mm3.

Older participants were more likely to be male, white, born in the UK, have been living with diagnosed HIV for at least ten years, be taking ART and have an undetectable viral load.

At least one distressing physical symptom was reported by 56% of people and 11% reported having ten or more distressing symptoms. The most commonly reported symptoms were a lack of energy (26%), difficulty sleeping (24%), feeling tired (24%), aches and pains (21%) and sexual problems (19%).
No trend was found in the prevalence of physical symptoms with age (AOR = 0.96; 95% CI 0.79-0.94, p = 0.36). Moreover, people aged 60 years and older had the lowest prevalence of physical symptoms compared to all other age groups.

However, time since HIV diagnosis was strongly related to the prevalence of symptom distress (p < 0.001). There were also differences according to gender/sexual orientation. Compared to MSM, the prevalence of distressing symptoms tended to be lower among heterosexual men, but higher among women.

Depression was present in 27% of people and 22% reported anxiety. The prevalence of these mental health problems tended to decrease with age. But once again, longer time since HIV diagnosis was strongly associated with a higher prevalence of both depression and anxiety (p < 0.001).

The overall prevalence of health-related functional problems was 38%. Just over a quarter (27%) reported mobility problems, 12% problems with self-care and a third had problems performing usual activities. The prevalence of functional problems significantly increased with age. They were also strongly associated with longer time since HIV diagnosis (p < 0.001).

“With older age, people living with HIV reported a higher prevalence of health-related functional problems, but a lower prevalence of depression and anxiety symptoms,” write the investigators. “Longer time with diagnosed HIV infection, however, was related to a higher prevalence of all self-rated health problems: symptom distress, depression, anxiety and each domain of functional problems, independent of age.”

The authors believe their findings have clear implications for the design of services for ageing people living with HIV.

“The strong and consistent associations between longer time with diagnosed HIV infection and poorer self-reported health, even after accounting for age, suggest a need for supportive strategies for people who have lived with HIV for a long period of time…and emphasize the importance of regular care and ongoing evaluation of psychological health, even for individuals who are virologically stable on ART,” they conclude.

“Independent associations of both older age and longer time since HIV diagnosis with physical health problems emphasise the importance of screening and assessment for age-related conditions among people under care for HIV infection, and prompt referral to suitable services.”

Objectives: An increasing proportion of people living with HIV are older adults, who may require specialized care. Adverse physical and psychological effects of HIV infection may be greatest among older people or those who have lived longer with HIV.
Methods: The ASTRA study is a cross-sectional questionnaire study of 3258 HIV-diagnosed adults (2248 men who have sex with men, 373 heterosexual men and 637 women) recruited from UK clinics in 2011–2012. Associations of age group with physical symptom distress (significant distress for at least one of 26 symptoms), depression and anxiety symptoms (scores ≥ 10 on PHQ-9 and GAD-7, respectively), and health-related functional problems (problems on at least one of three domains of the Euroqol 5D-3L)) were assessed, adjusting for time with diagnosed HIV infection, gender/sexual orientation and ethnicity.
Results: The age distribution of participants was: < 30 years, 5%; 30–39 years, 23%; 40–49 years, 43%; 50–59 years, 22%; and ≥ 60 years, 7%. Overall prevalences were: physical symptom distress, 56%; depression symptoms, 27%; anxiety symptoms, 22%; functional problems, 38%. No trend was found in the prevalence of physical symptom distress with age [adjusted odds ratio (OR) for trend across age groups, 0.96; 95% confidence interval (CI) 0.89, 1.04; P = 0.36]. The prevalence of depression and anxiety symptoms decreased with age [adjusted OR 0.86 (95% CI 0.79, 0.94; P = 0.001) and adjusted OR 0.85 (95% CI 0.77, 0.94; P = 0.001), respectively], while that of functional problems increased (adjusted OR 1.28; 95% CI 1.17, 1.39; P < 0.001). In contrast, a longer time with diagnosed HIV infection was strongly and independently associated with a higher prevalence of symptom distress, depression symptoms, anxiety symptoms, and functional problems (P < 0.001 for trends, adjusted analysis).
Conclusions: Among people living with HIV, although health-related functional problems were more common with older age, physical symptom distress was not, and mental health was more favourable. These results suggest that a longer time with diagnosed HIV infection, rather than age, is the dominating factor contributing to psychological morbidity and lower quality of life.

McGowan JA, Sherr L, Rodger AJ, Fisher M, Miners A, Anderson J, Johnson MA, Elford J, Collins S, Hart G, Phillips AN, Speakman A, Lampe FC

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