According to a recent report by the Chinese Ministry of Health, the proportion of people age 50 or older living with HIV/AIDS (PLWHAs) among the total reported HIV cases in China increased 11-fold from 1.9% in 2000 to 21.1% in 2011 [
The aging of the AIDS epidemic is occurring globally, not just in China. By 2015, about half of PLWHAs in the United States will be 50 years of age or older [
Living with HIV/AIDS can be extremely challenging at any age, but older PLWHAs have to contend with the physical declines of an aging body. As both aging and HIV infection can work separately or interactively to reduce human immune response, older PLWHAs are particularly susceptible to AIDS related or non-AIDS related chronic diseases [
In addition, the interaction of aging processes and AIDS-associated conditions can create considerable psychosocial challenges for older PLWHAs. Social relationships may become strained or disrupted due to HIV’s association with stigmatizing behaviors and also through social discrimination [
Despite the rapidly increasing number of older adults living with the virus globally, little research to date has compared psychosocial health of older PLWHAs to younger PLWHAs [
To understand the psychological challenges that older adults confront living with HIV and also to obtain baseline data for further research, we conducted a study of older PLWHAs in China. Consistent with other HIV research [
The study protocol and consent procedures were reviewed and approved by the Institutional Review Boards of Virginia Commonwealth University and Guangxi Center for Disease Control and Prevention. In accordance with the approved protocol, written informed consent was obtained from all study participants prior to data collection.
The cross-sectional study was conducted in Nanning, the capital city of the Guangxi Province. In 2011, Guangxi ranked second among China’s 31 provinces for reported number of HIV infections. Although about 30% of all PLWHAs (including both younger and older ones) in Nanning acquired HIV through heterosexual intercourses and 45% through needle-sharing, the dominant HIV transmission mode among older adults was heterosexual (90%) [
A two-stage sampling approach was used to recruit eligible subjects [
In addition to collecting basic demographic information, we administered four well-validated scales to assess quality of life, general self-efficacy, subjective well-being, and depression. The demographic items and scales initially were drafted in English and then translated into Chinese by three research team members who were fluent in both languages. The Chinese version of the measurement items was then distributed to research team members for further review and word-modified to assure that the measures were appropriate within a Chinese context. The four scales are as follows.
The above measurement scales have been used successfully in other studies with Chinese populations [
Chi-square tests were used to determine statistical differences in demographic variables (i.e., gender, education, and marital status) between older and younger PLWHAs. Pearson’s correlation coefficients were calculated to measure bivariate correlations. The comparisons of psychosocial and mental health between older and younger PLWHAs were conducted using Student’s
A total of 170 PLWHAs were invited to participate in the study. Of these, 20 PLWHAs declined participation due to unavailability (
Demographic characteristics of two subsamples.
Older PLWHAs* |
Younger PLWHAs* |
|
|
---|---|---|---|
Gender | 0.53 | ||
Female | 8 (25.8) | 37 (31.6) | |
Male | 23 (74.2) | 80 (68.4) | |
Education | 0.06 | ||
No school or primary school | 12 (38.7) | 26 (22.2) | |
Middle school or above | 19 (61.3) | 91 (77.8) | |
Marital status | 0.02 | ||
Unmarried | 4 (12.9) | 40 (34.2) | |
Married | 27 (87.1) | 77 (65.8) | |
Years after HIV diagnosis | 0.19 | ||
<1 | 15 (48.4) | 42 (35.9) | |
1-2 | 12 (38.7) | 42 (35.9) | |
≥3 | 4 (12.9) | 33 (28.2) | |
Being on ART | 0.48 | ||
Yes | 15 (48.4) | 65 (55.6) | |
No | 16 (51.6) | 52 (44.4) |
*People living with HIV/AIDS.
Using a cut-off score of 10 or more to classify participants as having depressive symptoms [
Three out of four quality of life domains (physical health, psychological, and social relationships) were significantly lower among older PLWHAs when compared to younger PLWHAs (Table
Distributions of HIV knowledge, self-efficacy, well-being, depression and quality of life.
Crude mean (SD) | Adjusted mean2 | |||||
---|---|---|---|---|---|---|
Older PLWHAs |
Younger PLWHAs |
|
Older PLWHAs |
Younger PLWHAs |
|
|
HIV knowledge1 | 8.5 (3.9) | 10.1 (2.3) | 0.20 | 9.3 | 10.3 | 0.07 |
Self-efficacy1 | 24.6 (3.4) | 25.3 (3.4) | 0.34 | 23.9 | 24.6 | 0.31 |
Depression | 13.6 (5.6) | 10.8 (6.5) | 0.03 | 18.6 | 15.8 | 0.03 |
Well-being | 7.8 (5.6) | 11.7 (6.3) | <0.01 | 7.6 | 11.4 | <0.01 |
Quality of life: | ||||||
Physical health | 10.4 (2.8) | 12.2 (2.9) | <0.01 | 10.3 | 11.9 | <0.01 |
Psychological1 | 10.1 (2.4) | 11.4 (2.8) | 0.02 | 9.5 | 10.9 | 0.01 |
Social relationships | 12.0 (2.5) | 13.0 (2.6) | 0.05 | 11.8 | 12.9 | 0.05 |
Environment1 | 10.5 (2.7) |
10.8 (2.4) | 0.41 | 9.8 |
10.2 | 0.32 |
1Logarithmic transformation was applied.
2Adjusted for gender, education, and marital status, being on ART, and years after HIV diagnosis.
Correlations of self-efficacy, depression, well-being, and quality of life among older PLWHAs.
Depression | Well-being | Physical | Psychological | Social | Environment | |
---|---|---|---|---|---|---|
Self-efficacy | 0.18 | −0.28 | −0.13 | 0.16 | 0.26 | 0.23 |
Depression |
|
|
|
−0.05 | −0.13 | |
Well-being |
|
|
|
| ||
Quality of life: | ||||||
Physical health |
|
|
| |||
Psychological |
|
| ||||
Social relationships |
| |||||
Environment | 1.00 |
Although the demographic profile of the HIV epidemic in China is rapidly aging, this is the first study, to our knowledge, to examine psychological and mental health status among older PLWHAs. Our findings show that when compared to younger PLWHAs, older PLWHAs exhibited significantly greater symptoms of depression, poorer well-being, and poorer quality of life in three domains: physical health, psychological health, and social relationships. We also found that a higher level of depression among older PLWHAs was associated with much lower levels of subjective well-being and quality of life (physical health and psychological domain).
Overall participants in our study were found to experience symptoms of clinical depression irrespective of age. This finding is consistent with reports from USA showing depression rates for HIV-positive adults to be twice that of the general population [
Our data also show that older PLWHAs in this study had poorer quality of life than adult PLWHAs reported in other studies. Shan et al. reported that the physical, psychological, social, and environmental domain scores were 12.9, 12.4, 14.0, and 12.5, respectively, among adult PLWHAs aged between 29 and 60 years old [
In contrast to our expectation, the level of general self-efficacy among older and younger PLWHAs is comparable to the level reported from other studies among Chinese general populations. In a study of 1,003 participants in Hong Kong [
Despite experiences of significant adversity, individuals with strong resilience may have positive adaptation or coping skills [
Several limitations to this study should be noted. First, due to the nature of a preliminary study with a small sample size, we could not fully investigate and address potential psychosocial factors contributing to depression and quality of life through more complex and in-depth data analysis. Large-scale studies are needed to examine the interaction effects of aging in tandem with psychological and mental health factors among older PLWHAs. Second, the single study site with an intentionally chosen convenience sample may limit the generalizability of our findings. Third, the study relied on self-reported data and consequently may be subject to both recall and social desirability bias. Also, previous studies have found gender differences in reported quality of life in older adults. Due to the small sample size, we could not investigate these differences.
Despite these limitations, our study provides preliminary information regarding the extent to which older PLWHAs in China confront psychological challenges. The findings demonstrate that older PLWHAs reported lower well-being and experienced greater depressive symptoms and poorer quality of life when compared to younger PLWHAs. When coupled with the normal processes of aging and AIDS-associated conditions, the psychosocial and mental health challenges faced by older PLWHAs may go well beyond those of their younger HIV-infected counterparts. Because it was a preliminary study, factors determining the impaired psychological and physical functions and their consequences were not fully investigated. Further research with a larger sample of older PLWHAs is needed to confirm our findings and to understand how aging can accelerate disease progression and affect the psychosocial and mental well-being of older adults living with HIV.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors are grateful to the staff from Nanning Center for Disease and Control for participation in the study and to all the participants who gave so willingly their time to provide the study data. This study was conducted when Dr. Hongjie Liu worked at Virginia Commonwealth University School of Medicine. This work was partially supported by a research Grant (R01 HD068305-01) from the NIH-NICHD and a research Grant from the Virginia Commonwealth University School of Medicine. The Chicago Developmental Center for AIDS Research provided additional assistance (P30 AI 082151).