Clinical Characteristics and Outcomes Among Older Women with HIV

Abstract

Objectives:

To inform the development of HIV care strategies for older women with HIV infection, an understudied group, we compared the psychosocial, behavioral, and clinical characteristics of HIV-positive women aged ≥50 (older women) with those aged 18–49 (younger women).

Methods:

We examined factors among HIV-positive women in care using data from the 2009 through 2013 cycles of a nationally representative sample of HIV-positive adults in care (Medical Monitoring Project). We compared psychosocial, clinical, and behavioral factors among women aged ≥50 years at interview versus those aged <50 years. We calculated weighted frequency estimates and performed logistic regression to compute adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) for the comparison of characteristics among women aged ≥50 versus <50 years.

Results:

Of 22,145 participants, 6186 were women; 40.7% (CI 39.1–42.3) were ≥50 years, and 32.7% of older women reported being sexually active. Compared with women <50 years, women aged ≥50 years were more likely to be dose adherent (aPR = 1.19; CI 1.07–1.33), prescribed antiretroviral therapy and have sustained viral load suppression (aPR = 1.03; CI 1.00–1.18), and were less likely to report any depression (aPR = 0.92; CI 0.86–0.99), to report condomless sex with a negative or unknown partner if sexually active (aPR = 0.56; CI 0.48–0.67), and to have received HIV/sexually transmitted infection (STI) prevention counseling from a healthcare provider (aPR = 0.82; CI 0.76–0.88).

Conclusions:

These data suggest that older women in HIV care have more favorable outcomes in some clinical areas, but may warrant increased HIV/STI prevention counseling from their care providers, especially if sexually active.

Introduction

Largely due to improved treatment and management of HIV, and better-tolerated antiretroviral therapy (ART) medications, HIV-positive persons are living longer and healthier lives and are better coping with comorbid health challenges that arise.^1,2 Consequently, among all persons living with diagnosed HIV infection, the proportion age ≥50 years increased from 35% in 2010 to 42% in 2013, and accounted for 17% of the 44,073 new HIV diagnoses in 2014.³ As the population of older HIV-positive persons grows, there is an increased need for age-appropriate, ongoing HIV care, treatment, and prevention services for them. Data show that even successfully treated HIV-positive persons ≥50 years of age without AIDS-related comorbidities have a lower median survival time compared with those in the general population (matched by age and gender), which underscores that continued research to understand factors affecting morbidity and mortality in older HIV-positive persons is vital.⁴

By the end of 2013, of all persons ≥50 years of age living with diagnosed HIV infection in the United States, women comprised 22.5%.⁵ Women comprised 26.5% of all persons aged 50 years and older diagnosed with HIV in 2014.⁵ For HIV-positive women taking effective ART, longer life expectancy means many women are living well into their postmenopausal years and require tailored, comprehensive medical care and treatment.

To date, several reports have described the natural history, prevalence, and treatment response of menopausal symptoms among older women living with HIV infection.^6

–9 However, little is known about general factors associated with aging among HIV-positive women compared with younger HIV-positive women, and how to tailor HIV care and support more specifically for older women.^10,11 We compared the social, behavioral, and clinical characteristics of HIV-positive women ≥50 years of age (older women) with those aged 18–49 years (younger women) from a nationally representative sample of HIV-positive persons receiving care. Understanding the differences among these women by age groups may inform the development of HIV prevention and care strategies that are relevant and effective for older women with HIV infection.

Methods

Data and study design

We analyzed matched interview and medical record abstraction data from the 2009 through 2013 data collection cycles of the Medical Monitoring Project (MMP). MMP is an HIV surveillance system that provides annual, nationally representative estimates of behavioral and clinical characteristics of HIV-positive adults receiving medical care in the United States. MMP used a probability proportionate to size sampling design; the MMP sample was selected in three stages.

During the 2009 through 2013 data cycles, U.S. states and territories were sampled, followed by providers at outpatient facilities providing HIV care, and finally by HIV-infected adults aged 18 years and older who reported at least one medical care visit in a participating facility during January through April of each data cycle. For state and territory samples, the probability of selection was proportionate to AIDS prevalence; for provider samples, the probability of selection was proportionate to the HIV-infected patient census.^12

–16 Data were collected via face to face interviews and medical record abstractions for HIV positive and age 18 years or older, and had received medical care in participating facilities between January and April in the cycle year for which they were sampled.^* All sampled states and territories participated in MMP.

Each participant's record was weighted to account for known probabilities of selection for each state or territory, by facility, and for patients from selected facilities. In addition, using information collected from sampled facilities and sampled patients, we completed an analysis to compare respondents and nonrespondents. Data were also weighted to adjust for nonresponse using predictors of patient-level response (e.g., facility size, facility type [public or private], participant race or ethnicity, time since HIV diagnosis, and age group).^13,14

The number of participating facilities ranged from 461 to 480 (median = 473) from the 2009 to 2013 data cycles. Of sampled patients, the number of patients who completed interviews and had their medical record abstracted ranged from 4217 to 5030 (median = 4503). The median facility response and patient response rates, adjusted for eligibility, ranged from 76% to 85% (median = 83%) and from 52% to 56% (median = 55%).

Analysis criteria

We combined data from the MMP 2009–2013 data collection cycles (n = 22,145); then, we restricted our analyses to women, who represented 26%–28% of all participants over the years (n = 6186). The analysis sample was stratified into two groups: women aged ≥50 years (older women) and women aged 18–49 years (younger women) at the time of interview.

Measures

Demographic, social, and behavioral variables

Sociodemographic variables collected for the MMP analyses included race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, or other); education attainment (<high school, high school diploma, or >high school); length of time since HIV diagnosis (<5, 5–9, ≥10 years); and poverty level (at or below, above). The following social and behavioral variables were reported by respondents based on the 12 months before being interviewed: incarceration, homelessness, type of healthcare coverage, smoking, drug use (both injection and noninjection) for nonmedical purposes, any sexual activity, and any condomless sex with a negative or unknown status partner. Binge drinking in the 30 days before being interviewed was defined as four or more drinks per day for women. Any depression in the past 2 weeks, based on the eight-item Patient Health Questionnaire Depression Scale (PHQ-8), was defined as a score of ≥10.¹⁷ The number and percentage of participants meeting current poverty guidelines were determined using the U.S. Department of Health and Human Services poverty guidelines¹⁸ that corresponded to the calendar year about which the combined household income was asked. The HIV disease stage as per Centers for Disease Control and Prevention (CDC) criteria, Stage 1, no AIDS and nadir CD4⁺ T lymphocyte (CD4) ≥0.500 × 10⁹ cells/L (or CD4% ≥29); Stage 2, no AIDS and nadir CD4 0.200–0.499 × 10⁹ cells/L (or CD4% 14 to <29); or Stage 3, AIDS or nadir CD4 count 0–0.199 × 10⁹ cells/L [or CD4% <14], was determined.¹⁹

Clinical care and treatment indicators

Clinical variables were abstracted from participants' medical records for the year before the MMP interview and included the following: documented prescription of ART, geometric mean CD4 count (0–199, 200–499, or ≥500 cells/mm³), most recent HIV RNA viral load suppression (defined as most recent viral load documented as undetectable or <200 copies/mL), sustained viral suppression (defined as all viral loads in the past 12 months as undetectable or <200 copies/mL), medical record documentation of results from a Pap test, and testing for gonorrhea, chlamydia, or syphilis. Using the interview instrument, participants reported if they were currently taking ART and if they were taking ART, their ART medication taking behaviors, and if they had received HIV and sexually transmitted infection (STI) prevention counseling by a health professional in the past year. If the participant reported that they took the prescribed dose of ART medications in the 3 days before interview, they were classified as 100% dose adherent (hereafter referred to as “dose adherent”).

Data analyses

Weighted estimates of percentages and associated 95% confidence intervals (CIs) were computed to describe the characteristics of HIV-positive women aged ≥50 versus <50 years. Bivariate associations between the selected independent variables and younger and older women were tested using the Rao–Scott chi-square tests.²⁰

We performed logistic regression to compute unadjusted and adjusted prevalence ratios (aPR) and 95% CIs for the association between psychosocial, behavioral, and clinical factors with being aged ≥50 versus <50 years. All characteristics with a p-value <0.05 were retained in the final multivariate logistic model. We also identified and included strong social determinants in the model and assessed differences between younger and older women. For all variables in the model, we computed adjusted prevalence estimates (predicted marginal percentages) and prevalence ratios, with 95% CIs among all levels of each characteristic associated with younger and older HIV-positive women, using multiple logistic regression analysis after controlling for the selected characteristics.^21,22

All analyses were performed using SAS 9.3 (SAS Institute, Cary, NC) and SAS-callable SUDAAN 10.0.1 (RTI International, Research Triangle Park, NC), and accounted for clustering, unequal selection probabilities, and nonresponse.

Ethics statement

In accordance with guidelines for defining public health research,²³ CDC-determined MMP was public health surveillance used for disease control, program, or policy purposes. Local institutional review board approval was obtained at participating states, territory, and facilities when required. Informed consent was obtained from all interviewed participants.

Results

In 2009–2013 MMP data cycles, women represented 26.4% of the sample (Table 1). Among HIV-positive women in care, 40.7% were aged ≥50 years, 60.5% were non-Hispanic black, and 64.6% were at or below poverty level. Also, 27.2% reported any depression in the previous 2 weeks, 67.2% of participants had Stage 3 disease (clinical or immunologic AIDS), 51.5% were sexually active, 12.0% reported condomless sex with an HIV-negative or unknown HIV status partner, and 39.3% were current smokers.

Table 1.

Selected Sociodemographic and Behavioral Characteristics of HIV-Infected Women Receiving Medical Care by Age Groups in the United States: Medical Monitoring Project, 2009–2013 (n = 6186)

	Total		<50 years		≥50 years
Characteristics	n	%^a (95% CI)	n	%^a (95% CI)	n	%^a (95% CI)	Chi-square ^h p
Total	6186	100	3672	59.3 (57.7–60.9)	2514	40.7 (39.1–42.3)
Sociodemographic
Race/ethnicity							0.5073
White, non-Hispanic	995	17.4 (15.1–19.7)	605	18.1 (15.6–20.6)	390	16.3 (13.4–19.2)
Black, non-Hispanic	3716	60.5 (55.1–65.8)	2196	59.7 (54.5–64.9)	1520	61.6 (55.4–67.7)
Hispanic or Latino^b	1265	18.5 (13.6–23.3)	749	18.6 (14.0–23.2)	516	18.3 (12.8–23.7)
Other	210	3.7 (2.9–4.4)	122	3.6 (2.7–4.5)	88	3.8 (2.9–4.8)
Education attainment							0.3054
<High school	2057	32.5 (30.9–34.2)	1203	32.0 (30.1–33.8)	854	33.4 (31.0–35.7)
High school graduate	1940	31.0 (29.6–32.4)	1179	31.8 (29.9–33.8)	761	29.9 (28.0–31.8)
>High school	2184	36.4 (34.4–38.5)	1286	36.2 (33.9–38.5)	898	36.7 (34.2–39.3)
Length of time since HIV diagnosis							<0.0001
<5 years	1186	20.1 (18.8–21.4)	844	24.1 (22.4–25.9)	342	14.3 (12.8–15.9)
5–9 years	1423	23.2 (21.9–24.4)	952	26.5 (24.7–28.2)	471	18.3 (16.5–20.2)
≥10 years	3574	56.7 (55.0–58.5)	1874	49.4 (47.2–51.6)	1700	67.4 (64.9–69.8)
Health insurance coverage or coverage for medications							<0.0001
Any private insurance	1212	20.7 (18.8–22.7)	722	20.6 (18.5–22.7)	490	20.9 (18.4–23.3)
Public insurance only	4032	63.3 (61.0–65.6)	2291	60.2 (57.3–63.1)	1741	67.7 (65.1–70.4)
Ryan White program coverage only	754	13.1 (11.3–15.0)	520	15.4 (13.1–17.7)	234	9.9 (8.2–11.5)
Uninsured	173	2.9 (2.1–3.6)	132	3.8 (2.8–4.8)	41	1.5 (0.9–2.0)
At or below household poverty level	3925	64.6 (62.3–67.0)	2415	67.6 (65.1–70.2)	1510	60.3 (57.1–63.5)	<0.0001
Homelessness	502	7.7 (6.9–8.6)	351	9.1 (8.0–10.3)	151	5.6 (4.7–6.6)	<0.0001
Incarcerated	267	4.4 (3.7–5.1)	213	5.9 (5.0–6.8)	54	2.2 (1.4–2.9)	<0.0001
Any depression in the past 2 weeks^c	1640	27.2 (25.4–29.0)	1042	29.6 (27.5–31.6)	598	23.8 (21.5–26.1)	<0.0001
Sexual behavior
Sexually active	3209	51.5 (50.0–53.0)	2369	64.5 (62.6–66.5)	840	32.7 (30.6–34.7)	<0.0001
Condomless sex with a negative or unknown partner	749	12.0 (11.0–13.0)	589	16.0 (14.4–17.6)	160	6.3 (5.2–7.4)	<0.0001
Substance use
Binge drinking in past 30 days	639	10.3 (9.4–11.1)	439	12.0 (11.0–13.1)	200	7.7 (6.5–9.0)	<0.0001
Current smoker	2411	39.3 (37.5–41.2)	1466	40.1 (37.9–42.3)	945	38.1 (35.6–40.7)	0.1860
Any drug use	1026	16.6 (15.3–17.9)	711	19.7 (18.2–21.3)	315	12.1 (10.5–13.8)	<0.0001
Clinical characteristics
HIV disease stage^d,e							<0.0001
Stage 1 (HIV)	500	8.7 (7.9–9.6)	328	9.4 (8.2–10.5)	172	7.8 (6.5–9.1)
Stage 2 (HIV)	1471	24.1 (22.7–25.5)	990	27.3 (25.5–29.2)	481	19.3 (17.5–21.1)
Stage 3 (HIV and AIDS)	4194	67.2 (65.5–68.9)	2341	63.3 (61.2–65.4)	1853	72.9 (70.6–75.2)
Prescribed ART^d	5609	90.5 (89.7–91.4)	3281	89.0 (87.8–90.2)	2328	92.7 (91.6–93.8)	<0.0001
Currently taking ART	5532	89.9 (88.8–90.9)	3207	87.4 (86.0–88.8)	2325	93.5 (92.4–94.6)	<0.0001
100% Dose adherence^f	4534	75.6 (74.1–77.1)	2570	71.6 (69.7–73.5)	1964	81.5 (79.6–83.4)	<0.0001
Viral suppression
Sustained viral suppression^d,g	3662	59.1 (57.4–60.8)	1998	54.6 (52.5–56.7)	1664	65.6 (63.5–67.8)	<0.0001
Most recent viral suppression^b,d	4435	71.5 (69.9–73.1)	2482	67.5 (65.8–69.3)	1953	77.2 (75.0–79.4)	<0.0001
Had at least one VL every 6 months in past year^d	4553	73.4 (71.4–75.4)	2655	72.6 (70.5–74.8)	1898	74.6 (72.1–77.1)	0.1209
Geometric mean CD4 count (cells/mm³)^d							<0.0001
0–199	675	11.0 (10.0–12.0)	463	12.4 (11.2–13.7)	212	8.9 (7.6–10.2)
200–499	2098	35.4 (34.0–36.9)	1293	37.5 (35.6–39.3)	805	32.4 (30.2–34.7)
500+	3113	53.6 (52.0–55.1)	1739	50.1 (48.0–52.1)	1374	58.7 (56.4–60.9)
Receipt of prevention services
HIV/STI prevention counseling by a healthcare professional	3171	49.7 (46.9–52.5)	2060	54.7 (51.7–57.6)	1111	42.4 (38.9–45.8)	<0.0001
Pap test^d	2204	35.0 (32.5–37.4)	1397	37.6 (34.7–40.6)	807	31.1 (28.6–33.6)	<0.0001
STI testing among sexually active
Gonorrhea testing^d	1177	35.3 (32.4–38.2)	885	36.1 (32.9–39.4)	292	33.0 (29.1–36.9)	0.1258
Chlamydia testing^d	1217	36.6 (33.6–39.6)	909	37.1 (33.9–40.4)	308	35.1 (31.1–39.2)	0.3237
Syphilis testing^d	1793	52.0 (48.5–55.6)	1335	52.7 (49.0–56.5)	458	50.1 (45.7–54.5)	0.1878
Survey year							<0.0001
2009	1139	18.8 (16.6–21.0)	779	21.8 (19.4–24.2)	360	14.4 (12.1–16.8)
2010	1182	19.1 (16.6–21.7)	717	19.9 (17.1–22.7)	465	18.0 (15.4–20.7)
2011	1191	20.5 (17.7–23.4)	704	20.0 (17.0–23.0)	487	21.3 (18.1–24.5)
2012	1268	19.8 (17.7–21.9)	733	19.0 (16.7–21.3)	535	21.0 (18.6–23.5)
2013	1406	21.7 (18.9–24.5)	739	19.2 (16.3–22.2)	667	25.2 (21.9–28.6)

Time period: in the past 12 months, unless otherwise noted. All measures are self-reported unless otherwise noted.

Weighted column percentage.

Hispanics or Latinos can be of any race.

Any depression in the past 2 weeks, based on the PHQ-8, defined as a score of ≥10.

Based on medical record abstraction data in the past 12 months before interview.

The stages are as follows: Stage 1, no AIDS and nadir CD4 ≥ 500 copies/mL or CD4% ≥ 29; Stage 2, no AIDS and nadir CD4 between 200 and 499 copies/mL or CD4% 14–29; Stage 3, AIDS or nadir CD4 between 0 and 199 copies/mL or CD4% <14%.

Dose adherent (or 100% dose adherent) refers to taking a dose or set of pills/spoonfuls/injections of ART medications as prescribed by the medical provider over the past 3 days.

Sustained viral suppression is defined as all viral loads in the last 12 months undetectable or <200 copies/mL.

Chi-square p-value based on the Rao–Scott chi-square.

ART, antiretroviral therapy; CI, confidence interval; n, unweighted sample size; PHQ-8, eight-item Patient Health Questionnaire Depression Scale; STI, sexually transmitted infection; VL, viral load.

By age group, there were significant differences (p < 0.05) in length of time since HIV diagnosis, type of health insurance coverage, poverty level, recent history of homelessness or incarceration, recent depression, sexual activity, binge drinking, any drug use, HIV disease stage, being prescribed ART, currently taking ART, dose adherence, viral suppression, mean CD4 count, having received STI prevention counseling by a healthcare professional, and having received a Pap test (Table 1).

In bivariate analysis, compared with women aged <50 years, women aged ≥50 years were significantly (p < 0.05) more likely to be dose adherent for the past 3 days, prescribed ART and be virally suppressed for the previous 12 months than not to be prescribed ART, and they were less likely to be uninsured or have Ryan White coverage only (hereafter referred to as “no insurance”). They were also less likely to be at or below household poverty level, homeless, or incarcerated. They were less likely to report symptoms consistent with depression and were less likely to have a Pap test documented in the medical chart. Detailed crude prevalence ratios are summarized in Table 2.

Table 2.

Crude and Adjusted Prevalence Ratios for Selected Characteristics Among Older (≥50 Years) HIV-Infected Women Receiving Medical Care, United States—Medical Monitoring Project, 2009–2013

	Unadjusted/bivariate analyses	Adjusted/multivariate analyses
Characteristics	PR (95% CI)	aPR (95% CI)	p
Length of time since HIV diagnosis			<0.001
<5 years	Reference	Reference
5–9 years	1.11 (0.98–1.26)	1.06 (0.93–1.21)
≥10 years	1.67 (1.50–1.86)	1.44 (1.30–1.60)
Type of health insurance			<0.001
Any private insurance	0.94 (0.87–1.03)	0.81 (0.73–0.90)
Public insurance only	Reference	Reference
Ryan White program coverage only	0.70 (0.62–0.80)	0.76 (0.68–0.85)
Uninsured	0.48 (0.35–0.67)	0.53 (0.36–0.78)
At or below household poverty level	0.83 (0.77–0.90)	0.84 (0.77–0.91)	<0.001
Homelessness	0.71 (0.62–0.82)	—	—
Incarceration^a	0.48 (0.36–0.64)	0.66 (0.50–0.86)	0.001
Any depression in the past 2 weeks^b	0.83 (0.77–0.90)	0.92 (0.86–0.99)	0.026
Condomless sex with a negative or unknown partner	0.49 (0.41–0.59)	0.56 (0.48–0.67)	<0.001
Binge drinker in past 30 days	0.73 (0.65–0.83)	—	—
Drug use	0.69 (0.62–0.77)	0.82 (0.75–0.90)	<0.001
Prescribed ART^c and sustained VL suppressed^a,c			<0.001
Prescribed ART and sustained VL suppressed	1.45 (1.25–1.68)	1.03 (1.00–1.18)
Prescribed ART and sustained VL not suppressed	1.14 (0.97–1.32)	0.88 (0.77–1.01)
Not prescribed ART	Reference	Reference
100% Dose adherence^d	1.42 (1.28–1.57)	1.19 (1.07–1.33)	0.001
Pap test documented in medical chart^a	0.84 (0.78–0.90)	0.87 (0.81–0.94)	<0.001
HIV/STI prevention counseling by a healthcare professional	0.74 (0.69–0.80)	0.82 (0.76–0.88)	<0.001
Survey year			<0.001
2009	Reference	Reference
2010	1.23 (1.11–1.36)	1.15 (1.05–1.26)
2011	1.35 (1.19–1.53)	1.24 (1.09–1.41)
2012	1.38 (1.22–1.56)	1.23 (1.09–1.39)
2013	1.52 (1.34–1.72)	1.36 (1.20–1.54)

Time period: in the past 12 months, unless otherwise noted. All measures are self-reported unless otherwise noted.

Based on medical record abstraction data in the past 12 months before interview.

Any depression in the past 2 weeks, based on the PHQ-8, defined as a score of ≥10.

Sustained viral suppression is defined as all viral loads in the last 12 months undetectable or <200 copies/mL.

Dose adherent (or 100% dose adherent) refers to taking a dose or set of pills/spoonfuls/injections of ART medications as prescribed by the medical provider over the past 3 days.

aPR, adjusted prevalence ratio (adjusted for all other factors in the model); n, unweighted sample size; PR, unadjusted prevalence ratio.

In multivariable analyses, compared with women <50 years of age, women aged ≥50 years were more likely to have been diagnosed with HIV longer (≥10 versus <5 years ago [aPR = 1.44]) and to have been prescribed ART and have sustained viral load suppression (aPR = 1.03) than to not have been prescribed ART and to be dose adherent the past 3 days (aPR = 1.19). They were less likely to have private insurance (aPR = 0.81) or no insurance versus public insurance (aPR = 0.53), to be at or below the household poverty level (aPR = 0.84), to have a history of incarceration (aPR = 0.66), to report symptoms consistent with depression in the previous 2 weeks (aPR = 0.92), to report condomless sex with an HIV-negative or unknown partner (aPR = 0.56), to have a Pap test result documented in their medical chart (aPR = 0.87), and to have received HIV/STI prevention counseling from a healthcare provider (aPR = 0.82). Detailed aPR are summarized in Table 2.

Furthermore, three levels of ART prescription and viral suppression—prescribed ART with sustained viral suppression, prescribed ART without sustained viral suppression, and not prescribed ART, were examined. We compared the percentages for those younger than 50 years compared to those older than 50 years in each of the three levels. We found that older women were more likely to have been prescribed ART and also have sustained viral load suppression than women <50 years of age, while younger women were less likely to have been prescribed ART (Fig. 1).

FIG. 1.

Percentage of ART prescription and durable viral suppression among older and younger women, MMP, 2009–2013. Numbers in boxes are adjusted prevalence ratios and 95% confidence intervals comparing selected characteristics between older (≥50 years) and younger (<50 years) HIV-infected women in MMP. The prevalences and prevalence ratios are based on the results from the multivariate model in Table 2. ART, antiretroviral therapy; MMP, Medical Monitoring Project; VL, viral load.

Discussion

Among HIV-positive women in care from 2009 to 2013, differences between older women and younger women suggest that older women fared better on several indicators of social determinants of health, such as having healthcare insurance and less poverty. Older women also had more favorable HIV clinical status, as they were more likely to be prescribed ART, be dose adherent, and have sustained viral suppression.

In terms of HIV sexual risk behaviors, older HIV-positive women also differed from their younger counterparts. Compared to younger women, older women were less likely to be sexually active and were less likely to report condomless sex with a male partner. However, for older women who were sexually active or engaged in risk behaviors, sexual health and behavioral issues may not always be adequately addressed. Older HIV-positive women who were sexually active were less likely than their younger counterparts to be screened for gonorrhea, chlamydia, and syphilis, and only 42% of women older than 50 years reported receiving HIV/STI prevention counseling by their healthcare providers. Previous studies have documented that providers underestimate sexual activity by older patients.^24,25 Providers may need reinforced messages regarding the continued importance of sexual risk-reduction messages for older patients living with HIV.^24,26

Reinforced messages regarding routine health screenings for HIV-positive women, in general, may also be needed. Based on our results, routine STI and Pap testing among all sexually active HIV-positive women—regardless of age—was suboptimal (<40% for Pap, gonorrhea, or chlamydia screening and <53% for syphilis screening) in outpatient HIV clinical care settings. Clinical guidelines recommend annual screening for gonorrhea, chlamydia, and syphilis among persons who are sexually active.²⁷ Annual Pap tests are also recommended for women who are living with HIV, although more recent evidence suggests that increasing time between Pap tests may be warranted in cases where multiple negative results are obtained.²⁸ HIV care interventions that strengthen routine STI clinical screenings for women by providers may be warranted.

We also found that older women were more likely than younger women to have a suppressed viral load, as measured by either most recent viral load or all viral loads over the past 12 months. In addition, a larger proportion of older women (72.9%) had Stage 3 HIV disease stage compared with 63.3% of younger women, which perhaps reflects the fact that a higher proportion of older women in our sample had lived with HIV for ≥10 years and had more time to have an AIDS-defining diagnosis at some point. Nevertheless, viral suppression among women overall appears to be suboptimal, with 71.5% of the women in our sample achieving viral suppression at their most recent viral load; this is below the national target of viral suppression for 80% of all HIV-positive persons. Lack of viral suppression is associated with increased risks for ongoing HIV transmission. Data suggest that many women living with HIV are especially affected by social and structural barriers that create challenges to care, including poverty, lack of access, and community and individual stigma.^29
–31 In addition, these findings suggest the need for increased, targeted delivery of healthcare services and HIV/STI counseling services for older women. These challenges must be addressed and considered in the development of social and structural interventions that strengthen retention in care and adherence to ART medications for women.

In addition to social and structural barriers, poor mental health, which may affect treatment adherence and health-related behaviors, is a concern among individuals living with HIV infection.³² Our estimated prevalence of 27% for recent depression among HIV-positive women in care appears to be more than twice as high as that observed among women in the general population,³³ and is consistent with previous findings on depression among HIV-positive persons.³⁴ Symptoms consistent with any depression were less frequently reported by older than younger women in our study, and depression has been linked to a decreased likelihood of viral suppression.³⁵ Given the common occurrence of depression among HIV-infected persons, routine screening and monitoring for depression are an integral part of clinical HIV management, particularly in the context of treatment of nonadherence and unsuppressed viral load.

While some signs are positive for older women compared with younger women, the high prevalence of certain behaviors for all women warrants that public health efforts with women remain and get stronger. For example, overall, 12% of sexually active women in our sample reported condomless sex with an HIV-negative or unknown status male partner, which suggests multiple opportunities for sexual HIV transmission; stronger messages regarding use of condoms and availability of pre-exposure prophylaxis for uninfected partners³⁶ are warranted with both older and younger women. Another example is current smoking, which was reported by 39% of women in our sample with no differences by age group; this prevalence and the increased morbidity and mortality due to smoking among persons living with HIV³⁷ highlight the need to address smoking among women living with HIV. Smoking cessation remains an important public health goal to reduce both HIV and non-HIV-related morbidity and mortality, and should be discussed as a goal at each clinical encounter.^38,39

Limitations

This analysis was subject to some limitations. First, data are limited to HIV-positive women receiving care, not all HIV-positive women. Thus, the findings of this study cannot be generalized to HIV-positive women not receiving medical care. Second, there may be possible survivor bias among older women, as those available to participate may have additional behaviors that contributed to current HIV control and overall healthcare. Our data show that older women were more likely to be prescribed ART, be dose adherent, and be virally suppressed than younger women. More work is needed to better understand the differential prevalence of ART prescription and viral suppression to guide care for women by younger and older age groups. Third, for some variables, such as STI counseling, medical record documentation would provide more reliable data than patient report; future reports should strengthen medical records data abstraction for improved analyses and data interpretation. Fourth, since MMP is an observational, cross-sectional study, causality cannot be inferred. Fifth, our study had modest response rates and nonresponse bias is possible. Our sampling frame was based on a probabilistic sampling frame and allowed us to examine characteristics of sampled patients (sex, age, race, length of time since HIV diagnosis) to conduct a comparative analysis of respondents and nonrespondents. Research has shown that well-constructed samples with moderate rates have a reduced risk of bias.⁴⁰ Finally, although the average age of menopause is 51 years in the United States, and most women in our sample at or above age 50 were likely menopausal, that information was not collected as part of this data set and therefore not available to inform our analyses.

Conclusions

This multivariable analysis that compares older and younger women living with HIV by social, behavioral, and clinical factors adds to the limited research available on this topic. This report highlights the resilience of older women in some areas, but underscores the importance of continuing to deliver messages of medication adherence and sexual health with all HIV-positive women. In addition, messages for routine, clinical STI screening for all HIV-positive sexually active patients may need to be reinforced with clinical providers, along with information about reimbursement for these clinical services. By understanding more about issues across the life span for women living with HIV infection, we can better inform tailored interventions and strategies, and strengthen our ability to improve their outcomes related to HIV prevention and care, consistent with the National HIV/AIDS Strategy.⁴¹

Footnotes

Acknowledgments

We thank participating MMP patients, facilities, project areas, and Provider and Community Advisory Board members. We also acknowledge the contributions of the Clinical Outcomes Team and Behavioral and Clinical Surveillance Branch at CDC and the MMP 2009–2013 project areas (www.cdc.gov/hiv/statistics/systems/mmp/resources.html). Funding for the Medical Monitoring Project is provided by a cooperative agreement (PS09-937) from the CDC. The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the CDC.

Author Disclosure Statement

No competing financial interests exist.

References

Samji

, Cescon

, Hogg

, et al. Closing the gap: Increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One, 2013; 8:e81355.

Slomka

, Lim

, Gripshover

, Daly

. How have long-term survivors coped with living with HIV?. J Assoc Nurses AIDS Care, 2013; 24:449–459.

Centers for Disease Control and Prevention.. Diagnoses of HIV infection in the United States and dependent areas, 2014. HIV Surveillance Report, 2014, Vol. 26. Available at: www.cdc.gov/hiv/library/reports/surveillance Accessed January 12, 2017 .

Legarth

, Ahlstrom

, Kronborg

, et al. Long-term mortality in HIV-infected individuals 50 years or older: A nationwide, population-based cohort study. J Acquir Immune Defic Syndr, 2016; 71:213–218.

Centers for Disease Control and Prevention.. Diagnoses of HIV infection among adults aged 50 years and older in the United States and dependent areas, 2010–2014. HIV Surveillance Supplemental Report, 2016, Vol. 21. Available at: www.cdc.gov/hiv/library/reports/surveillance Accessed January 12, 2017 .

Andany

, Kennedy

, Aden

, Loutfy

. Perspectives on menopause and women with HIV. Int J Womens Health, 2016; 8:1–22.

Cejtin

. Care of the Human immunodeficiency virus-infected menopausal woman. Am J Obstet Gynecol, 2012; 207:87–93.

Calvet

, Grinsztejn

, Quintana Mde

, et al. Predictors of early menopause in HIV-infected women: A prospective cohort study. Am J Obstet Gynecol, 2015; 212:765.e1–e765.e13.

Santoro

, Fan

, Maslow

, Schoenbaum

. Women and HIV infection: The makings of a midlife crisis. Maturitas, 2009; 64:160–164.

10.

Schable

, Chu

, Diaz

. Characteristics of women 50 years of age or older with heterosexually acquired AIDS. Am J Public Health, 1996; 86:1616–1618.

11.

Stoff

, Colosi

, Rubstova

, Wingood

. HIV and aging research in women: An overview. Curr HIV/AIDS Rep, 2016; 13:383–391.

12.

Frankel

, McNaghten

, Shapiro

, et al. A probability sample for monitoring the HIV-infected population in care in the U.S. and in selected states. Open AIDS J, 2012; 6:67–76.

13.

Iachan

, Johnson

, Harding

, et al. Design and weighting methods for a nationally representative sample of HIV-infected adults receiving medical care in the United States-Medical Monitoring Project. Open AIDS J, 2016; 10:164–181.

14.

Bradley

, Frazier

, Huang

, et al. Behavioral and clinical characteristics of persons receiving medical care for HIV infection—Medical Monitoring Project, United States, 2013 Cycle. HIV Surveillance Special Report, 16, 2016. Available at: www.cdc.gov/hiv/library/reports/surveillance#panel2 Accessed January 12, 2017 .

15.

Bradley

, Frazier

, Huang

, et al. Behavioral and clinical characteristics of persons receiving medical care for HIV infection-Medical Monitoring Project, United States, 2010 Cycle. HIV Surveillance Special Report, 9, 2014. Available at: www.cdc.gov/hiv/library/reports/surveillance#special Accessed January 12, 2017 .

16.

Blair

, Fagan

, Frazier

, et al. Behavioral and clinical characteristics of persons receiving medical care for HIV infection—Medical Monitoring Project, United States, 2009. MMWR Suppl, 2014; 63 Suppl 5:1–22.

17.

Kroenke

, Strine

, Spitzer

, Williams

JBW

, Berry

, Mokdad

. The PHQ-8 as a measure of current depression in the general population. J Affect Disord, 2009; 114:163–173.

18.

U.S. Department of Health and Human Services (DHHS). Annual update of the HHS poverty guidelines. Fed Regist, 2009; 74:4199–4201.

19.

Centers for Disease Control and Prevention. Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years—United States, 2008. MMWR Recomm Rep, 2008; 57(RR-10):1–12.

20.

Rao

JNK

, Scott

. A simple method for the analysis of clustered binary data. Biometrics, 1992; 48:577–585.

21.

Bieler

, Brown

, Williams

, Brogan

. Estimating model-adjusted risks, risk differences, and risk ratios from complex survey data. Am J Epidemiol, 2010; 171:618–623.

22.

Korn

, Graubard

. Analysis of health surveys. New York, NY: John Wiley and Sons, Inc., 1999.

23.

Centers for Disease Control and Prevention.. Distinguishing public health research and public health nonresearch. 2010. Available at: www.cdc.gov/od/science/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf Accessed January 12, 2017 .

24.

Ports

, Barnack-Tavlaris

, Syme

, Perera

, Lafata

. Sexual health discussions with older adult patients during periodic health exams. J Sex Med, 2014; 11:901–908.

25.

Gott

, Hinchliff

, Galena

. General practitioner attitudes to discussing sexual health issues with older people. Soc Sci Med, 2004; 58:2093–2103.

26.

Centers for Disease Control and Prevention.. Recommendations for HIV prevention with adults and adolescents with HIV. Available at: www.cdc.gov/hiv/guidelines/personswithhiv.html Accessed January 12, 2017 .

27.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep, 2015; 64(RR-3):1–137.

28.

American College of Obstetricians and Gynecologists. Cervical cancer screening and prevention. Practice Bulletin No. 157. Obstet Gynecol, 2016; 127:e1–e20.

29.

Aziz

, Smith

. Challenges and successes in linking HIV-infected women to care in the United States. Clin Infect Dis, 2011; 52 Suppl 2:S231–S237.

30.

Johnson

, Samarina

, Xi

, et al. Barriers to access to care reported by women living with HIV across 27 countries. AIDS Care, 2015; 27:1220–1230.

31.

Loutfy

, Sherr

, Sonnenberg-Schwan

, Walmsley

, Johnson

, d' Arminio Monforte A. Caring for women living with HIV: Gaps in the evidence. J Int AIDS Soc, 2013; 16:18509.

32.

Sadock

, Sadock

, Ruiz

. Kaplan & Sadock's comprehensive textbook of psychiatry, Vol. I, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.

33.

Reeves

, Strine

, Pratt

, et al. Mental illness surveillance among adults in the United States. MMWR Surveill Summ, 2011; 60 Suppl 3:1–29.

34.

, Rosenberg

, Sullivan

, et al. Excess burden of depression among HIV-infected persons receiving medical care in the United States: Data from the medical monitoring project and the behavioral risk factor surveillance system. PLoS One, 2014; 9:e92842.

35.

Gokhale

, Bradley

, Garg

, Shouse

. HIV viral suppression among adults diagnosed with depression in the United States—Medical Monitoring Project, 2009–2012. Abstract presented at Conference on Retroviruses and Opportunistic Infections (CROI) 2016. Available at: www.croiconference.org/sites/default/files/posters-2016/1037.pdf Accessed January 12, 2017 .

36.

Centers for Disease Control and Prevention. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR, 2012; 61:586–589.

37.

Triplette

, Crothers

, Attia

. Non-infectious pulmonary diseases and HIV. Curr HIV/AIDS Rep, 2016; 13:140–148.

38.

Cornuz

. Smoking cessation interventions in clinical practice. Eur J Vasc Endovasc Surg, 2007; 34:397–404.

39.

Calvo-Sánchez

, Martinez

. How to address smoking cessation in HIV patients. HIV Med, 2015; 16:201–210.

40.

Groves

, Peytcheva

. The impact of nonresponse rates on nonresponse bias. Public Opin Q, 2008; 72:167–189.

41.

The White House Office of National AIDS Policy.. National HIV/AIDS strategy for the United States: Updated to. 2020. Available at: www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf Accessed January 12, 2017 .