Challenges of HIV/HCV Coinfection Among Older Adults

1. Challenges of HIV/HCV Coinfection Among Older Adults Karolynn Siegel, PhD, Helen-Maria Lekas, PhD, and Courtney J. Brown-Bradley, MPH Center for the Psychosocial Study of Health and Illness Mailman School of Public Health Columbia University

2. Symptoms and Illness Behaviors of HIV-Infected Adults • NIA funded study (R01 AG16571) • Principal Investigator: Karolynn Siegel, Ph.D. • In-depth interviews with 100 HIV+ adults (50+) in New York City area • Coinfection was not a focus of the study; data re coinfection are based primarily on spontaneous comments offered by participants • 38 participants reported HCV coinfection

3. Symptoms and Illness Behaviors of HIV-Infected Adults Objectives • To investigate the symptom appraisal process for common disease and treatment-related symptoms (i.e. the assigning of cause and significance to symptoms) of HIV-infected adults • To investigate HIV-infected adults’ coping responses to common disease and treatment-related symptoms • To investigate how symptoms influence HIV-infected adults’ treatment acceptance and adherence behaviors

4. Symptoms and Illness Behaviors of HIV-Infected Adults • Data were collected between November 2000 and February 2002 • Symptom and illness experiences were gathered using nondirective focused interviewing techniques • Text coded using content/thematic analysis • Atlas.ti used to facilitate analysis

5. HIV/HCV Coinfection • Hepatitis C – common comorbidity among PLWHA, especially IDU • Population prevalence estimates: • 3%-15% among HIV+ homosexual/bisexual men • 30% to >90% among HIV+ IDU • Extended longevity due to HAART allowing for manifestation of long-term effects of HCV • Increase in percentage of deaths in HIV+ patients attributable to liver disease

6. HIV/HCV Coinfection • HCV progression may be accelerated in the presence of HIV • Challenges in the clinical management of coinfection • Timing of treatments • Hepatotoxicity of HAART regimens • Potential drug interactions • Limited data on safety, tolerance and effectiveness of HCV treatment regimens among PLWHA • Neuropsychiatric side effects of interferon

7. Coinfection Sample Demographics • 58% male; 42% female • 55% Black, 24% Hispanic, 13% White, & 8% classified as “other” • Age: Mean = 55; Range = 50-68 • 76% < 60 years of age • Time since diagnosis: Mean = 9 years and 4 months; Range = 42 - 174 months • Ever had T-cell count <200: 74% • History IVDU: 63%; Current IVDU: 5%

8. Coinfection Sample Demographics • Education: 24% < HS; 24% HS grad; 32% some college; 21% grad of 4-year college or more • Annual Income: 61% < $10,000; 26% - $10 – 19,999; 13% > $25,000 • Sexual orientation: 60% completely heterosexual, 11% completely homosexual • Marital status: 3% common law marriage; 47% separated/divorced; 16% widowed; 34% single never married. • Partner status/ living situation: 34% had steady partner; 68% lived alone • Children: 74% had children; 18% had children living in their home

9. Findings:Challenges of HIV/HCV Coinfection • Coinfection influences older HIV+ adults perceptions of and management of each condition and their overall health status • Coinfection may affect symptom interpretation, treatment decisions and perceptions of illness and self.

10. Coinfection and Symptom Interpretation • “Don’t know who’s messing with me today.” • Uncertainty over attribution of symptoms to HIV, HCV, age, or medication • Physicians not always able to diminish uncertainty • Some were uncertain what (if any) symptoms are typically associated with HCV • Degree of threat associated with attributions to HIV or HCV varied

11. Coinfection and Treatment Decisions • Treatment decision-making a challenge filled with uncertainty for this population • Complex medical profiles • Very few had received ribavirin/interferon treatment (current: n=2; past: n=3) • Questionable efficacy of available HCV treatments

12. Coinfection and Treatment Decisions • Some considered HCV treatment “dangerous” while offering “no guarantees” • “Not effective enough for me to risk the side-effects.” • Fears and concerns over the outcomes of treating or not treating HCV (i.e. perceived as a no-win situation) • Attitudes and beliefs about HCV treatments informed by peer groups and HCPs

13. Coinfection and Treatment Decisions • Fear of liver damage from HIV therapies • Discontinuation of HAART because of liver function abnormalities • Close monitoring by physician for adverse effects on liver • Treatment interruptions to give their “liver a break” • Use of CAM during interim • Concerns over liver toxicity also altered medical treatment of symptoms

14. Coinfection and Perceptions of Self and Illness • HIV + HCV = “Double Jeopardy” • Differing opinions about which disease is more threatening • HCV may accelerate the progression of HIV and vice versa • Feelings of hopelessness about future health • Uncertainty over illness trajectory • Issues of stigma

15. Challenges of HIV/HCV Coinfection Among Older Adults Conclusion • Persons coinfected with HIV and HCV may not be enjoying the lessened threat associated with HIV in the HAART era • Coinfected individuals are challenged to simultaneously manage two difficult, chronic, and potentially fatal diseases • Treatment decision-making, symptom interpretation and management, stigma management, & maintenance of physical and emotional health all appear to be more complicated for PLWHA coinfected with HCV