Abstract
Introduction: Miami is the city with the highest prevalence of HIV in the U.S., and, like other parts of the country, there are growing numbers of older adults living with HIV. Life instability, or the cumulative negative effect of variables increasing unpredictability, chaos, and confusion in an individual’s life, may be an important factor for mental health and HIV outcomes in older adults living with HIV. However, a dearth of research exists examining life instability and associated variables in this population. The present study examined the degree to which life instability affects HIV-related health outcomes – continuous log RNA viral load, antiretroviral (ART) medication adherence, CD4-cell count, rates of viral suppression, and HIV-care appointment non-adherence among older adults (50+) with HIV in the Miami area. We hypothesized that greater levels of life instability will be associated with worse mental health (depression and anxiety), worse adherence to antiretroviral therapy, reduced odds of viral suppression, higher levels of continuous log RNA viral load, lower CD4-cell count, and HIV-care appointment non-adherence. Further, we hypothesized that the effects of life instability on health behaviors and each of the HIV outcomes will operate, at least partially, through their association with poorer overall mental health functioning.
Methods: From Apr 2017- April 21, 2020, 623 patients (50 years +, living in Miami-Dade County) in the primary public HIV clinic in Miami completed an interviewer-administered assessment (English or Spanish), and data were matched with patients’ HIV RNA viral load and CD4 via database linkages. A series of correlations were conducted to examine the relationships among indicators of life instability at both individual and community levels. An additive model of life instability was then created by adding each of the 11 indicators of life instability to create a life instability index. Simple linear regression analyses were conducted to assess the relationship between the life instability index and ART adherence, continuous log RNA viral load, CD4-cell count, and HIV-care appointment non-adherence. A logistic regression model was utilized to evaluate the relationship between the life instability index and viral suppression among participants. Additional linear and logistic regression models were run using Hayes’ SPSS PROCESS macro to assess whether any observed effects of life instability on these variables operate indirectly through depression, anxiety, and substance use.
Results: The average age of participants (N = 623) was 57.99 years (SD = 5.90) and ranged between 50 - 80 years. 65.9% of the sample identified as Black-non-Hispanic compared to only 3.6% of participants self-identifying as White-non-Hispanic. 60.8% of participants identified as a cisgender male and 80.6% of participants self-identified as heterosexual. Among our sample of 623 older adults with HIV (OAWH), participants reported about six instabilizing factors each (M = 6.08, SD = 1.44). The index of life instability was significantly associated with worse ART adherence (b = -1.14, C.I. [-2.15, -0.12], p = 0.03), lower HIV-care appointment adherence (b = -0.02, C.I. [-0.03, -0.01,]), p < 0.01), lower continuous log RNA viral load (b = 0.09, C.I. [0.02, 0.17], p = 0.02), and lower odds of viral suppression (OR = 1.22, C.I. [1.06, 1.40], p = 0.01), but was not associated with continuous CD4-cell count (b = 4.34, C.I. [-16.53, 25.20], p = 0.68). Regarding psychological distress, life instability was significantly associated with increased substance use among participants (b= 0.08, SE = 0.02, C.I. [0.04, 0.13], p < 0.01), trended towards significance for higher anxiety symptoms (b = 0.17, SE = 0.09, C.I. [-0.02, 0.36], p = 0.07), and exhibited no signs of statistically significant relationship with depression scores (b = 0.16, SE = 0.15, C.I. [-0.13, 0.46], p = 0.27). Analyses to establish indirect effects predominately yielded null findings; however, the relationships between life instability and ART adherence via substance use was significant.
Discussion: Although there is literature surrounding the relationship between life instability and HIV-related health outcomes, research is minimal, especially as it relates to older adults with HIV. This present study is the first to examine how an additive index of factors of life instability at both the individual and community level may affect HIV-related health outcomes among a population of OAWH (aged 50 years or older) living in an epicenter of the U.S. HIV epidemic. The results suggest that an 11-item additive index of factors of life instability is significantly associated with measures of HIV disease severity including poorer viral suppression and higher levels of continuous log RNA viral load, as well as other poor HIV-related health outcomes such as ART adherence and HIV-care appointment attendance among OAWH receiving HIV care at two public HIV clinics in Miami, Florida. Further, the findings from this study indicate that OAWH facing a greater number of life instabilizing factors report significantly higher levels of substance use and that in certain circumstances, substance use can explain the relationship between our predictor of interest (measure of life instability) and our various outcomes of interests (measures of HIV disease severity, ART adherence, and HIV-care visit non-adherence). Taken together, these results suggest that compounding factors of life instability among OAWH may lead to poorer HIV-related health outcomes via measures of psychological distress (i.e., anxiety, depression, and substance use). However, longitudinal research is needed to further examine whether these indicators of psychological distress mediate the relationship between life instability and factors of HIV disease severity and treatment progression among OAWH.