Social Isolation and Retention in Care among Older Adults Living with HIV/AIDS Restricted; Files Only

Abstract

Background: Social isolation manifests in objective and subjective forms and affects health care utilization (HCU) behaviors. Yet, studies with persons living with HIV (PLWH) have focused primarily on objective isolation (social network size) and less is known about subjective isolation (loneliness) and its potential influence on HCU behaviors. An essential HCU behavior for positive health outcomes among PLWH is retention in care (RIC), and even less is known among older PLWH. This study sought to identify determinants of loneliness and to explore a path model of social isolation on RIC via emotion dysregulation among older PLWH, guided by the modified Theoretical Model of Loneliness. Differences in characteristics by the levels of RIC were explored.

Methods: Older PLWH (age ≥50) recruited from a single HIV clinic completed a baseline questionnaire on demographics, social network size, loneliness, emotion dysregulation, HIVrelated stigma, HIV-disclosure status, depressive symptoms, comorbidities, functional status, and substance abuse. Their RIC (i.e., adherence to HIV medical visits) and clinical data (HIV biomarkers, emergent HCU) were abstracted from electronic medical records (EMR) for 12- months post-baseline. Multivariable linear regression and path analysis were used.

Results: A total of 146 completed the baseline study questionnaire (60% male, 86% Black/African American, Mage=56) and 144 had RIC data. Multivariable regression analysis revealed that depressive symptoms and HIV-related stigma explained 41% of the variance in loneliness, controlling for covariates (R²=0.41, F(7, 138)=13.76, p<0.001). RIC was dichotomized (0=suboptimal [≤85%], 1=optimal appointment adherence [>85%]) and was related to monthly income (B=0.80, p=.07), drug abuse (B=-0.28, p=.02), and baseline CD4+ T cell count (B=1.45, p=.05) in regression analysis. Fit indices reflected a good fit of the proposed path model: χ²=8.81 (p=.46), CFI=1.00, TLI=1.01, RMSEA<0.001 (90% CI: 0.00-0.09). However, there were no direct or indirect effects of social isolation on RIC.

Conclusions: The current study underscores the importance of targeting HIV-related stigma and depression to reduce loneliness. Socioeconomic and behavioral vulnerabilities including low income and drug abuse are closely linked to suboptimal level of RIC among older PLWH. Focused intervention efforts to reduce disparities in RIC are needed.

Table of Contents

Chapter 1: Introduction ................................................................................................................ 1

Specific Aims................................................................................................................................ 1

Background.................................................................................................................................. 5

Older Persons Living with HIV/AIDS in the United States................................................................ 5

Retention in Care......................................................................................................................... 6

Social Isolation............................................................................................................................ 7

Social Isolation and Health Care Utilization Behaviors.................................................................... 12

Emotion Dysregulation ................................................................................................................ 14

Conceptual Framework ................................................................................................................ 16

Methods...................................................................................................................................... 17

Research Design........................................................................................................................... 17

Rationale for Sample Characteristics.............................................................................................. 18

Setting & Human Subjects Involvement.......................................................................................... 18

Recruiting Clinic Characteristics .................................................................................................... 18

Data Collection and Procedures...................................................................................................... 19

Data Management ........................................................................................................................ 20

Measures....................................................................................................................................... 21

Data Analysis................................................................................................................................ 26

Outline of the Dissertation............................................................................................................. 28

References .................................................................................................................................... 29

Chapter 2: A Systematic Review of Loneliness in Older Persons Living with HIV/AIDS....................... 46

Abstract...................................................................................................................................... 47

Introduction ............................................................................................................................... 48

Methods..................................................................................................................................... 51

Results ....................................................................................................................................... 53

Discussion.................................................................................................................................. 61

References ................................................................................................................................. 70

Chapter 3: Determinants of Loneliness in Older Persons Living with HIV/AIDS................................ 78

Abstract...................................................................................................................................... 79

Introduction ............................................................................................................................... 80

Methods..................................................................................................................................... 84

Participants & Setting................................................................................................................. 84

Data Collection........................................................................................................................... 84

Measures..................................................................................................................................... 85

Data Analysis.............................................................................................................................. 89

Results ....................................................................................................................................... 90

Discussion.................................................................................................................................. 92

References ............................................................................................................................... 102

Chapter 4: Social Isolation and Retention in Care in Older Persons Living with HIV/AIDS ...............112

Abstract.....................................................................................................................................113

Introduction ..............................................................................................................................114

Methods................................................................................................................................... 121

Study Design ............................................................................................................................ 121

Participants & Setting............................................................................................................... 121

Data Collection......................................................................................................................... 122

Measures.................................................................................................................................. 123

Data analysis ............................................................................................................................ 127

Results ..................................................................................................................................... 129

Discussion................................................................................................................................ 141

References ............................................................................................................................... 151

Chapter 5: Summary and Conclusions....................................................................................... 162

Summary of Results................................................................................................................. 162

Research and Clinical Implications............................................................................................ 165

References ............................................................................................................................... 172

About this Dissertation

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School	Laney Graduate School
Department	Nursing
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Psychology, Behavioral Sciences Health Sciences, Nursing Health Sciences, Aging
Keyword	retention in care appointment adherence older adults HIV/AIDS social network size loneliness social isolation
Committee Chair / Thesis Advisor	Waldrop-Valverde, Drenna, Emory University
Committee Members	Hepburn, Kenneth, Emory University Holstad, Marcia, Emory University Haardörfer, Regine, Emory University

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