Is self-rated successful ageing achievable in older women living with HIV, despite health complications they are likely to be confronted by?
Published by Dr Anna Rubotsva and colleagues in the Journal of Acquired Immune Deficiency Syndromes, a recent survey strongly suggests so: in 386 HIV-positive and 137 HIV-negative women, aged 50 years or over, successful ageing was reported by most women, with no differences by HIV status (83.7% and 82.5% in the two groups, respectively).
Defining successful ageing
Successful ageing is generally defined as the absence or avoidance of disease and disability, retaining a high level of physical and cognitive function, and active engagement with life. This broad definition can be fine-tuned. For example, in a qualitative study published in 2017, older people living with HIV defined successful ageing in terms of six key themes:
- Accepting limitations
- Staying positive
- Maintaining social support
- Taking responsibility
- Living a healthy lifestyle
- Engaging in meaningful activities.
Some researchers have looked at individuals’ own holistic evaluation of how well they were ageing, termed “self-rated successful ageing”. At least two studies have shown that many people with HIV report successful ageing. However, since they were conducted among a majority of male and white participants, their outcomes cannot be generalised to women who face medical and psychosocial challenges that are unique to their gender.
Older women living with HIV in the US
In the US, the number of older women with HIV is steadily growing, due to the combination of new HIV diagnoses in older people and greater longevity of people taking antiretroviral therapy (ART). However, ageing with HIV increases the likelihood of co-morbidities (including cardiovascular disease, depression and cancer), frailty, polypharmacy, substance abuse, social discrimination and stigma.
Additionally, HIV-positive women in general fare less well than their male counterparts, in terms of health outcomes, access to care, adherence, viral suppression, quality of life, morbidity and mortality.
Another key epidemiological fact to consider is that most older women living with HIV in the US belong to ethnic minorities. In 2015, 58% were African American – and it is known that belonging to an ethnic minority often intersects with many social vulnerabilities.
The specific objective of the investigators was to examine the prevalence and correlates of self-rated successful ageing among HIV-positive women and a comparison group of HIV-negative women.
Participants were already included in the Women’s Interagency HIV Study (WIHS), a large US cohort that, for decades, has collected data through follow up visits every six months, from women living with or at risk of HIV who are demographically similar. Each WIHS visit consists of an interview, clinical examination and laboratory testing.
In four WIHS sites, between 2017 and 2018, each of the women over the age of 50 was asked to complete an additional survey which included validated scales used in previous research, to assess self-rated successful ageing.
Other parameters such as levels of coping with stress, social support, medical outcomes, spirituality, anxiety, depression, loneliness, lifetime experience of discrimination, traumatic life events, sociodemographic characteristics were also captured.
On average, participants were 57 years old. The majority of them were African American (74%), unemployed and not married or partnered. In relation to these results, no differences were found according to HIV status.
Over one third of women in both groups had high school or less education. However, levels of education were lower in HIV-negative women than in HIV-positive women. Moreover, HIV-negative women had:
- Higher chances of having a very low annual income, no health insurance and not owning their own home.
- Higher substance use.
- Lower quality of life and optimism.
- Higher perceived lifetime discrimination.
The women living with HIV had high rates of ART use (94%), undetectable viral load (73%) and high CD4 cell counts (median was 750), indicating well-controlled HIV disease.
Not only was the high prevalence of self-rated successful ageing found at the same level in both HIV-positive and HIV-negative women, but also through three different measures which, importantly, were highly and significantly correlated:
- ‘Using your own definition, where would you rate yourself in terms of “successful ageing”, from “1” (least successful) to “10” (most successful)?’ In both groups, the women scored an average of 8. Among women with HIV, 83.7% scored over 7 and among HIV-negative women, 82.5% scored over 7.
- ‘Do you agree with the statement: “I am ageing well” (from 1 = definitely false, to 4 = definitely true)?’ The average reported score was 3.
- ‘Rate your current life on a scale from “1” (worst life possible) to “10” (best life possible).’ The average score in both groups was 8.
Women who reported higher levels of positive psychosocial factors, such as personal mastery, optimism, resilience and spirituality were more likely to report successful ageing. By contrast, those who reported negative psychosocial factors, such as anxiety, depression, loneliness and a history of a lifetime discrimination, were the ones to show the lowest rates of successful ageing. This concretely means, for example, that in whatever group any survey participant was, being depressed had a negative impact on her rating of successful ageing.
"The investigators highlight the importance of spirituality for African Americans, many of whom perceive religion as essential to their lives."
The investigators highlight the importance of spirituality for African Americans, many of whom perceive religion as essential to their lives. Spirituality may facilitate resilience to vulnerabilities, which in turn, probably facilitates successful ageing.
The survey did not reveal strong relationships between successful ageing and sociodemographic characteristics, HIV disease characteristics and co-morbidities.
Overall, the levels of successful ageing observed in this study are comparable with those of HIV-negative participants seen in previous studies with predominantly white male populations (e.g. in one study, 82% in HIV-negative people vs 67% in HIV-positive people).
But the main finding of the survey – the equivalent rates of self-reported successful ageing in the two groups of women – is surprising. Based on the evidence already described, the investigators had hypothesised that women living with HIV would do poorer than their HIV-negative counterparts.
It may be that in this study, the negative impact of HIV was counterbalanced by the greater social disadvantages among HIV-negative study participants. Also, the participants were involved in a long-term research study, with regular contact with healthcare providers, and very likely benefitting from social support when needed. It is possible that outside of WIHS, they would have had more difficulties.
“Nevertheless, these are important findings suggesting that high levels of self-reported successful ageing are achievable in older women living with HIV,” conclude Rubotsva and colleagues. The team of researchers also highlight that to their best knowledge, “this is the first published report of self-reported successful ageing among older women living with HIV”.
A small step, maybe, but a very important one in this field, where research must be pursued.
Rubtsova AA et al. Prevalence and Correlates of Self-Rated Successful Aging Among Older Women Living With HIV. Journal of Acquired Immune Deficiency Syndromes 82: S162-S169, 2019 (open access).