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Psychosocial and Demographic Correlates of Drug Use in a Sample of HIV-Positive Adults Ages 50 and Older

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Abstract

The prevalence of HIV among adults 50 and older in the USA is increasing as a result of improvements in treatment and detection of HIV infection. Substance use by this population has implications for physical and mental health outcomes. We examined patterns of demographics, mental health, and recent substance use in a diverse sample of heterosexual, bisexual, and gay adults 50 and older living with HIV/AIDS (PLWHA) in New York City. The most commonly used substances were cigarettes or alcohol; however, the majority of the sample did not report recent use of marijuana, poppers, or hard drugs (crystal methamphetamine, cocaine, crack, heroin, ecstasy, GHB, ketamine, and LSD or PCP). Statistically significant associations between substance use and psychological states (well-being and loneliness) were generally weak, and depression scores were not significantly related to use; instead, drug use was associated with gender/sexual orientation. The study observations support addressing substance use specific to subpopulations within PLWHA.

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References

  • Ahmad, K. (2002). Addictive drug increases HIV replication and mutation. The Lancet Infectious Diseases, 2, 456. doi:10.1016/S1473-3099(02)00360-2.

    Article  PubMed  Google Scholar 

  • American Lung Association. (2010). Smoking out a deadly threat: Tobacco use in the LGBT community. Washington, DC. Retrieved from http://www.lung.org/assets/documents/publications/lung-disease-data/lgbt-report.pdf. Accessed 7 Aug 2012.

  • Beckett, M., Burnam, A., Collins, R. L., Kanouse, D. E., & Beckman, R. (2003). Substance use and high-risk sex among people with HIV: A comparison across exposure groups. AIDS and Behavior, 7, 209–219. doi:10.1023/A:1023906610710.

    Article  PubMed  Google Scholar 

  • Benshoff, J., Harrawood, L., & Koch, D. (2003). Substance abuse and the elderly: Unique issues and concerns. Journal of Rehabilitation, 69, 43–48.

    Google Scholar 

  • Bertholet, N., Cheng, D. M., Quinn, E., Samet, J. H., & Saitz, R. (2010). Alcohol consumption patterns in HIV-infected adults with alcohol problems. Drug and Alcohol Dependence, 112, 160–163. doi:10.1016/j.drugalcdep.2010.05.009.

    Article  PubMed Central  PubMed  Google Scholar 

  • Bing, E. G., Burnam, M. A., Longshore, D., Fleishman, J. A., Sherbourne, C. D., London, A. S., & Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Archives of General Psychiatry, 58, 721–728. doi:10.1001/archpsyc.58.8.721.

    Article  CAS  PubMed  Google Scholar 

  • Braitstein, P., Palepu, A., Dieterich, D., Benhamou, Y., & Montaner, J. S. G. (2004). Special considerations in the initiation and management of antiretroviral therapy in individuals coinfected with HIV and hepatitis C. AIDS, 18, 2221. doi:10.1097/00002030-200411190-00002.

    Article  PubMed  Google Scholar 

  • Brennan, M., Karpiak, S. E., Shippy, A. R., & Cantor, M. H. (Eds.). (2009). Older adults with HIV: An in-depth examination of an emerging population. New York: Nova.

    Google Scholar 

  • Buka, S. L. (2002). Disparities in health status and substance use: Ethnicity and socioeconomic factors. Public Health Reports, 117, S118–S125.

    PubMed Central  PubMed  Google Scholar 

  • Buscher, A. L., & Giordano, T. P. (2010). Gaps in knowledge in caring for HIV survivors long-term. Journal of the American Medical Association, 304, 340–341. doi:10.1001/jama.2010.870.

    Article  CAS  PubMed  Google Scholar 

  • Carrico, A. W., Johnson, M. O., Moskowitz, J. T., Neilands, T. B., Morin, S. F., Charlebois, E. D., & NIMH Health Living Project Team. (2007). Affect regulation, stimulant use, and viral load among HIV-positive persons on anti-retroviral therapy. Psychosomatic Medicine, 69, 785. doi:10.1097/PSY.0b013e318157b142.

    Article  PubMed  Google Scholar 

  • Centers for Disease Control and Prevention. (2008a). Fact sheet: HIV/AIDS among persons aged 50 and older. U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm. Accessed 31 May 2011.

  • Centers for Disease Control and Prevention. (2008b). Cigarette smoking among adults—United States, 2007. Morbidity and Mortality Weekly Report, 57, 1221–1226.

    Google Scholar 

  • Centers for Disease Control and Prevention. (2011a). HIV Surveillance Report, 2009; vol. 21. U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Accessed 1 Jun 2011.

  • Centers for Disease Control and Prevention. (2011b). Vital signs: HIV prevention through care and treatment—United States. Morbidity and Mortality Weekly Report, 60, 1618–1623.

    Google Scholar 

  • Centers for Disease Control & Prevention. (1989). Reducing the health consequences of smoking: 25 years of progress—a report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC) 89–8411.

  • Centers for Disease Control & Prevention. (1990). The health benefits of smoking cessation: A report of the Surgeon General. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC) 90–8416.

  • Cook, J. A., Grey, D. D., Burke-Miller, J. K., Cohen, M. H., Vlahov, D., Kapadia, F., & Levine, A. M. (2007). Illicit drug use, depression and their association with highly active antiretroviral therapy in HIV-positive women. Drug and Alcohol Dependence, 89, 74–81. doi:10.1016/j.drugalcdep.2006.12.002.

    Article  PubMed Central  PubMed  Google Scholar 

  • Corless, I. B., Lindgren, T., Holzemer, W., Robinson, L., Moezzi, S., Kirksey, K., & Reynolds, N. (2009). Marijuana effectiveness as an HIV self-care strategy. Clinical Nursing Research, 18, 172–193. doi:10.1177/1054773809334958.

    Article  PubMed  Google Scholar 

  • Crystal, S., Akincigil, A., Sambamoorthi, U., Wenger, N., Fleishman, J. A., Zingmond, D. S., & Shapiro, M. F. (2003). The diverse older HIV-positive population: A national profile of economic circumstances, social support, and quality of life. Journal of Acquired Immune Deficiency Syndromes, 33, S76–S83. doi:10.1097/00126334-200306012-00004.

    Article  PubMed  Google Scholar 

  • Effros, R. B., Fletcher, C. V., Gebo, K., Halter, J. B., Hazzard, W. R., Horne, F. M., & High, K. P. (2008). Aging and infectious diseases: Workshop on HIV infection and aging: What is known and future research directions. Clinical Infectious Diseases, 47, 542–553. doi:10.1086/590150.

    Article  PubMed Central  PubMed  Google Scholar 

  • Emlet, C. A., Tozay, S., & Raveis, V. H. (2011). "I'm not going to die from the AIDS": Resilience in aging with HIV disease. The Gerontologist, 51, 101–111. doi:10.1093/geront/gnq060.

    Article  PubMed Central  PubMed  Google Scholar 

  • Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., & Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Diseases, 52, 793–800. doi:10.1093/cid/ciq243.

    Article  PubMed Central  PubMed  Google Scholar 

  • Gay Men’s Health Crisis (GMHC). (2010). Growing older with the epidemic: HIV and aging. Report by not-for-profit AIDS Service Organization, New York, NY. Retrieved from http://www.gmhc.org/files/editor/file/a_pa_aging10_emb2.pdf. Accessed 1 Jun 2011.

  • Giovino, G. A. (2002). Epidemiology of tobacco use in the United States. Oncogene, 21, 7326–7340. doi:10.1038/sj.onc.1205808.

    Article  CAS  PubMed  Google Scholar 

  • Golub, S. A., Botsko, M., Gamarel, K. E., Parsons, J. T., Brennan, M., & Karpiak, S. E. (2011). Dimensions of psychological well-being predict consistent condom use among older adults living with HIV. Ageing International, 36, 346–360. doi:10.1007/s12126-011-9113-4.

    Article  Google Scholar 

  • Gonzalez, J. S., Penedo, F. J., Antoni, M. H., Duran, R. E., McPherson-Baker, S., Ironson, G., & Schneiderman, N. (2004). Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS. Health Psychology, 23, 413–418. doi:10.1037/0278-6133.23.4.413.

    Article  PubMed  Google Scholar 

  • Grabar, S., Weiss, L., & Costagliola, D. (2006). HIV infection in older patients in the HAART era. Journal of Antimicrobial Chemotherapy, 57, 4–7.

    Article  CAS  PubMed  Google Scholar 

  • Greenwood, G. L., Paul, J. P., Pollack, L. M., Binson, D., Catania, J. A., Chang, J., & Stall, R. (2005). Tobacco use and cessation among a household-based sample of US urban men who have sex with men. American Journal of Public Health, 95, 145–151. doi:10.2105/AJPH.2003.021451.

    Article  PubMed Central  PubMed  Google Scholar 

  • Grov, C., Golub, S. A., Parsons, J. T., Brennan, M., & Karpiak, S. E. (2010). Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care, 22, 630–639. doi:10.1080/09540120903280901.

    Article  PubMed Central  PubMed  Google Scholar 

  • Gulliver, S. B., Kamholz, B. W., & Helstrom, A. W. (2006). Smoking cessation and alcohol abstinence: What do the data tell us? Alcohol Research & Health, 29, 208–212.

    Google Scholar 

  • Hansen, N. B., Cavanaugh, C. E., Connell, C. M., Sikkema, K. J., Tate, D. C., & Vaughan, E. L. (2009). The influence of personality disorder indication, social support, and grief on alcohol and cocaine use among HIV-positive adults coping with AIDS-related bereavement. AIDS and Behavior, 13, 375–384. doi:10.1007/s10461-007-9308-6.

    Article  PubMed Central  PubMed  Google Scholar 

  • Hatziandreu, E. J., Pierce, J. P., Lefkopoulou, M., Fiore, M. C., Mills, S. L., Novotny, T. E., & Davis, R. M. (1990). Quitting smoking in the United States in 1986. Journal of the National Cancer Institute, 82, 1402–1406. doi:10.1093/jnci/82.17.1402.

    Article  CAS  PubMed  Google Scholar 

  • Havlik, R. J., Brennan, M., & Karpiak, S. E. (2011). Comorbidities and depression in older adults with HIV. Sexual Health, 8, 551–559. doi:10.1071/SH11017.

    Article  PubMed  Google Scholar 

  • Heckman, T. G., Heckman, B. D., Kochman, A., Sikkema, K. J., & Goodkin, K. (2002). Psychological symptoms among persons age 50 years of age and older living with HIV disease. Aging & Mental Health, 6, 121–128. doi:10.1080/13607860220126709a.

    Article  CAS  Google Scholar 

  • Hinkin, C. H., Barclay, T. R., Castellon, S. A., Levine, A. J., Durvasula, S. A., Marion, S. D., & Longshore, D. (2007). Drug use and medication adherence among HIV-1 infected individuals. AIDS and Behavior, 11, 185–194. doi:10.1007/s10461-006-9152-0.

    Article  PubMed Central  PubMed  Google Scholar 

  • Hiscock, R., Bauld, L., Amos, A., Fidler, J. A., & Munafò, M. (2012). Socioeconomic status and smoking: A review. Annals of the New York Academy of Sciences, 1248, 107–123. doi:10.1111/j.1749-6632.2011.06202.x.

    Article  PubMed  Google Scholar 

  • Kalman, D. (1998). Smoking cessation treatment for substance misusers in early recovery: A review of the literature and recommendations for practice. Substance Use & Misuse, 33, 2021–2047. doi:10.3109/10826089809069815.

    Article  CAS  Google Scholar 

  • Kalman, D., Morissette, S. B., & George, T. P. (2005). Co-morbidity of smoking in patients with psychiatric and substance use disorders. The American Journal on Addictions, 14, 106–123. doi:10.1080/10550490590924728.

    Article  PubMed Central  PubMed  Google Scholar 

  • Karpiak, S. (2008, September). Reality demands change: The number of people over age 50 living with HIV continues to increase. GMHC Treatment Issues Newsletter, 21(2), 1–3. Retrieved from http://www.thebody.com/content/art44596.html. Accessed 6 Oct 2011.

  • Karpiak, S. E., Shippy, R. A. & Cantor, M. H. (2006). Research on older adults with HIV. New York: AIDS Community Research Initiative of America. Retrieved from http://www.health.ny.gov/diseases/aids/conferences/docs/roah_final_report.pdf. Accessed 10 May 2012.

  • Klinkenberg, W., & Sacks, S. (2004). Mental disorders and drug abuse in persons living with HIV/AIDS. AIDS Care, 16, 22–42. doi:10.1080/09540120412331315303.

    Article  Google Scholar 

  • Korthuis, P. T., Zephyrin, L. C., Fleishman, J. A., Saha, S., Josephs, J. S., McGrath, M. M., & Gebo, K. A. (2008). Health-related quality of life in HIV-infected patients: The role of substance use. AIDS Patient Care and STDs, 22, 859–867. doi:10.1089/apc.2008.0005.

    Article  PubMed Central  PubMed  Google Scholar 

  • Levy, J. A., Ory, M. G., & Crystal, S. (2003). HIV/AIDS interventions for midlife and older adults: Current status and challenges. Journal of Acquired Immune Deficiency Syndromes, 33, S59–S67. doi:10.1097/00126334-200306012-00002.

    Article  PubMed  Google Scholar 

  • Lucas, G. M., Cheever, L. W., Chaisson, R. E., & Moore, R. D. (2001). Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. Journal of Acquired Immune Deficiency Syndromes, 27, 251–259. doi:10.1097/00042560-200107010-00006.

    Article  CAS  PubMed  Google Scholar 

  • Lucas, G. M., Griswold, M., Gebo, K. A., Keruly, J., Chaisson, R. E., & Moore, R. D. (2006). Illicit drug use and HIV-1 disease progression: A longitudinal study in the era of highly active antiretroviral therapy. American Journal of Epidemiology, 163, 412. doi:10.1093/aje/kwj059.

    Article  PubMed  Google Scholar 

  • McGowan, C. C., Weinstein, D. D., Samenow, C. P., Stinnette, S. E., Barkanic, G., Rebeiro, P. F., & Hulgan, T. (2011). Drug use and receipt of highly active antiretroviral therapy among HIV-infected persons in two U.S. clinic cohorts. PLoS One, 6, 1–8. doi:10.1371/journal.pone.0018462.

    Google Scholar 

  • McKirnan, D. J., Ostrow, D. G., & Hope, B. (1996). Sex, drugs and escape: A psychological model of HIV-risk sexual behaviours. AIDS Care, 8, 655–669. doi:10.1080/09540129650125371.

    Article  CAS  PubMed  Google Scholar 

  • Myers, J. D. (2009). Growing old with HIV: The AIDS epidemic and aging population. Journal of American Academy of Physician Assistants, 22, 20–24.

    Article  Google Scholar 

  • New York City Department of Health and Mental Hygiene. (2011, October). HIV epidemiology & field services semiannual report, 6(2), 1–4. Retrieved from http://www.nyc.gov/html/doh/downloads/pdf/dires/2011_2nd_semi_rpt.pdf. Accessed 24 May 2012.

  • New York State Department of Health. (2007). Who’s smoking in New York? Retrieved from http://www.health.state.ny.us/prevention/tobacco_control/docs/2007-10_who_is_smoking_in_ny.pdf. Accessed 13 Sept 2011.

  • Pitts, M., Grierson, J., & Mission, S. (2005). Growing older with HIV: A study of health, social, and economic circumstances for people living with HIV in Australia over the age of 50 years. AIDS Patient Care and STDs, 19, 460–465. doi:10.1089/apc.2005.19.460.

    Article  PubMed  Google Scholar 

  • Power, L., Bell, M., & Freemantle, I. (2010). A national study of ageing and HIV (50 plus). Joseph Rowntree Foundation. Retrieved from http://www.jrf.org.uk/publications/over-50-living-with-HIV. Accessed 21 Jun 2011.

  • Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72, 1144–1156. doi:10.1037/0022-006X.72.6.1144.

    Article  PubMed  Google Scholar 

  • Rabkin, J. G., McElhiney, M. C., & Ferrando, S. J. (2004). Mood and substance use disorders in older adults with HIV/AIDS: Methodological issues and preliminary evidence. AIDS, 18, S43–S48.

    Article  PubMed  Google Scholar 

  • Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. doi:10.1177/014662167700100306.

    Article  Google Scholar 

  • Russell, D. W. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66, 20–40. doi:10.1207/s15327752jpa6601_2.

    Article  CAS  PubMed  Google Scholar 

  • Ryan, H., Wortley, P. M., Easton, A., Pederson, L., & Greenwood, G. (2001). Smoking among lesbians, gays, and bisexuals: A review of the literature. American Journal of Preventative Medicine, 21, 142–149. doi:10.1016/S0749-3797(01)00331-2.

    Article  CAS  Google Scholar 

  • Ryff, C. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069–1081. doi:10.1037//0022-3514.57.6.1069.

    Article  Google Scholar 

  • Sankar, A., Nevdeal, A., Neufeld, S., Berry, R., & Luborsky, M. (2011). What do we know about older adults and HIV? A review of social and behavioral literature. AIDS Care, 23, 118–1207. doi:10.1080/09540121.2011.564115.

    Article  Google Scholar 

  • Shippy, R. A., & Karpiak, S. E. (2005a). Perceptions of support among older adults with HIV. Research on Aging, 27, 290–306. doi:10.1177/0164027504273780.

    Article  Google Scholar 

  • Shippy, R. A., & Karpiak, S. E. (2005b). The aging HIV/AIDS population: Fragile social networks. Aging & Mental Health, 9, 246–254. doi:10.1080/13607860412331336850.

    Article  CAS  Google Scholar 

  • Simoni-Wastila, L., & Yang, H. K. (2006). Psychoactive drug abuse in older adults. The American Journal of Geriatric Pharmacotherapy, 4, 380–394. doi:10.1016/j.amjopharm.2006.10.002.

    Article  PubMed  Google Scholar 

  • Stoff, D. M. (2004). Mental health research in HIV/AIDS and aging: Problems and prospects. Journal of Acquired Immune Deficiency Syndromes, 18, S3–S10.

    Google Scholar 

  • Substance Abuse and Mental Health Services Administration [SAMHSA]. (1998). Substance abuse treatment among older adults. Treatment Improvement Protocol (TIP) Series 26. DHHS Publication No. (SMA) 98–3179. Rockville, MD.

  • Substance Abuse and Mental Health Services Administration [SAMHSA]. (2009). The NSDUH Report: Illicit drug use among older adults. Rockville, MD. Retrieved from http://oas.samhsa.gov/2k9/168/168OlderAdults.htm. Accessed 17 Mar 2011.

  • Substance Abuse and Mental Health Services Administration [SAMHSA]. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10–4586). Rockville, MD.

  • Substance Abuse and Mental Health Services Administration [SAMHSA]. (2011). Results from the 2009 National Survey on Drug Use and Health: Detailed Tables. Retrieved May 24, 2012 from http://www.samhsa.gov/data/NSDUH/2k10ResultsTables/Web/HTML/TOC.htm. Accessed 21 May 2012.

  • Tietz, D. (2010, Nov.). Older adults and HIV: A special report and action plan. AIDS Community Research Initiative of America. Retrieved from http://www.acria.org/files/ACRIA%20HIV-Aging%20Special%20Report%20Action%20Plan%2011.29.10%20FINAL.pdf. Accessed 31 Aug 2011.

  • Turner, B. J., Fleishman, J. A., Wenger, N., London, A. S., Burnam, M. A., Shaprio, M. F., & Bozzette, S. A. (2001). Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. Journal of General Internal Medicine, 16, 625–633. doi:10.1046/j.1525-1497.2001.016009625.x.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  • United States Senate Special Committee on Aging. (2005, May). HIV over fifty: Exploring the new threat (Committee on Aging Print 109–7). Retrieved from http://aging.senate.gov/publications/5122005.pdf. Accessed 31 May 2011.

  • Work Group for the HIV and Aging Consensus Project. (2012). Summary report from the human immunodeficiency virus and aging consensus project: Treatment strategies for clinicians managing older individuals with the human immunodeficiency virus. Journal of American Geriatrics Society, 60, 974–979. doi:10.1111/j.1532-5415.2012.03948.x.

    Article  Google Scholar 

  • Zanjani, F., Saboe, K., & Oslin, D. (2007). Age difference in rates of mental health/substance use and behavioral care in HIV-positive adults. AIDS Patient Care and STDs, 21, 347–355. doi:10.1089/apc.2006.0043.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Center for Health, Identity, Behavior & Prevention Studies (CHIBPS), Steinhardt School of Culture, Education & Human Development, New York University, 726 Broadway, Suite 525, New York, NY, 10003, USA

    Daniel E. Siconolfi, Perry N. Halkitis, Staci C. Barton, Molly J. Kingdon, Rafael E. Perez-Figueroa & Vanessa Arias-Martinez

  2. AIDS Community Research Initiative of America (ACRIA), New York, NY, USA

    Stephen Karpiak & Mark Brennan-Ing

  3. New York University College of Nursing, New York, NY, USA

    Stephen Karpiak & Mark Brennan-Ing

  4. Department of Population Health, Langone School of Medicine, New York University, New York, NY, USA

    Perry N. Halkitis

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  1. Daniel E. Siconolfi
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  2. Perry N. Halkitis
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Correspondence to Daniel E. Siconolfi.

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Siconolfi, D.E., Halkitis, P.N., Barton, S.C. et al. Psychosocial and Demographic Correlates of Drug Use in a Sample of HIV-Positive Adults Ages 50 and Older. Prev Sci 14, 618–627 (2013). https://doi.org/10.1007/s11121-012-0338-6

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