Social-environmental resiliencies protect against loneliness among HIV-Positive and HIV- negative older men who have sex with men: Results from the Multicenter AIDS Cohort Study (MACS)
Introduction
Given that the life expectancy of people living with HIV (PLWH) has increased and that men who have sex with men (MSM) now account for nearly two-thirds of the HIV/AIDS epidemic in the United States (Centers for Disease, Control, and Prevention, 2016), it is imperative to understand how to promote the health of older MSM defined as 40 years and over in this study. Loneliness—defined as the feeling of isolation regardless of objective social network size (Keefe et al., 2006)—is a key health risk for HIV-positive and HIV-negative older MSM (Marziali et al., 2020; Rendina et al., 2019). This psychosocial challenge is of great concern to clinicians, public health officials, and gerontologists, given the numerous adverse health outcomes frequently associated with prolonged periods of loneliness: an increased incidence of cardiovascular disease (Valtorta et al., 2018; Xia and Li, 2018), cognitive impairment (Luchetti et al., 2020; Yang et al., 2020), dementia progression (Holwerda et al., 2014; Sutin et al., 2018), and depressive symptomatology (Bergman and Segel-Karpas, 2018; Ge et al., 2017). Additionally, a report of any loneliness symptoms, including mild symptoms, has been associated with functional decline and increased mortality risk (Henriksen et al., 2019; Holt-Lunstad et al., 2015). To minimize the risk of older MSM with and without HIV infection developing these adverse health outcomes, it is imperative to identify factors that minimize loneliness in these vulnerable groups.
To date, studies examining loneliness among older PLWH or the subpopulation of HIV-positive older MSM reveal that loneliness is a pressing public health problem among these populations (Greene et al., 2018; Jacobs and Kane, 2012; Karpiak et al., 2006; Leyva-Moral et al., 2019; Marziali et al., 2020; Mazonson et al., 2020; Rendina et al., 2019; Su et al., 2018; Yoo-Jeong et al., 2019). The Research on Older Adults with HIV (ROAH) study assessed loneliness among older adults living with HIV (Karpiak et al., 2006). Half of the respondents were Black, a third Latino, and about 14% White. The remaining 4% identified as Asian/Pacific Islander, American Indian, or multi-ethnic (Karpiak et al., 2006). The study used the 20-item version of the UCLA Loneliness Scale (Russell, 1996), which is designed to assess perceptions of inadequate support from a person's social network. Results revealed an average score of 53 among participants (scores range from 20 to 80, with higher scores indicating a greater degree of loneliness) (Karpiak et al., 2006). A more recent study with older White (57%) and non-White/Latino participants (43%) living with HIV, who were primarily male, gay or bisexual, and in their mid-to-late 50s, demonstrated that 58% of them experienced some degree of loneliness (Greene et al., 2018). Lonely participants were more likely to report depression, alcohol, and tobacco use, and to have fewer relationships (Greene et al., 2018). In another study, 51% of older HIV-positive persons, the majority of whom were male (89%), gay (77%), and white (69%), were classified as lonely (Mazonson et al., 2020). The prevalence of loneliness was lower in the older age group (60 plus) compared to the “younger old” group (50–59 years) and may be explained by lower rates of depression and lower likelihood of feeling distant from friends among the older individuals (Mazonson et al., 2020). While previous studies demonstrate that loneliness is common among older HIV-positive MSM, these studies are limited in that none of them have a HIV-negative control group.
Given the high prevalence of loneliness among the older MSM population, particularly among HIV-positive older MSM, it is crucial to uncover more evidence about this public health concern and develop effective interventions aimed at reducing loneliness and promoting health. The concept of resilience has received growing attention in the public health literature. Efforts have increased to better understand how gay men promote and protect their health and well-being in the presence of adversity (Buttram, 2015; Herrick et al., 2011; Russell et al., 2003). Resilience is conceptualized as a process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress; this dynamic process involves the interplay of risk and protective factors (Masten and Powell, 2003; Yates and Masten, 2004). Although a risk factor such as loneliness is conceptualized as an adverse experience that can have negative effects on adaptive functioning and health, resiliencies that emanate from interpersonal and social environment sources may serve as protective factors against loneliness (Marziali et al., 2020; Rendina et al., 2019).
In particular, more evidence is needed to elucidate the role of resiliencies in the social environment such as social support, social networks, and social cohesion, which have been found to have a positive impact on health (Berkman and Glass, 2003; De Jesus et al., 2010; De Silva et al., 2005; Fiori et al., 2006; Ziersch et al., 2005). Social support is defined as having someone who can loan money, help out when sick, run errands, provide transportation, help with other tasks or take time to listen or to help deal with problems (Barrera, 1981). Social networks are the number and types of social connections one has including spouse/partner, close relatives and friends, and membership in church group or in other community organizations (Berkman and Syme, 1979). Social cohesion refers to the extent of connectedness and solidarity among groups (Kawachi and Berkman, 2000). These social environmental factors may increase resilience and in turn, may buffer against loneliness in persons living with HIV ages 40 years or older.
Several studies among HIV-positive MSM have demonstrated the positive impact of social environment resiliencies on health (Li et al., 2015; Ramirez-Valles et al., 2002, 2005; Rosario et al., 2001; Shao et al., 2018). One study showed that social support utilization—defined as the degree of utilizing various types of available support, such as seeking help from others and participating in social activities—was negatively associated with depression and anxiety among HIV-positive MSM in China (Shao et al., 2018). In another study, access to community resources was positively associated with perceived connectedness to the gay/bisexual community, and in turn was protective against loneliness among a sample of primarily White (84%), gay (77%) men, and HIV-negative (64%) (Li et al., 2015). Similarly, another study revealed that community involvement in AIDS and gay-related organizations among HIV-positive Latino gay men buffered against the adverse effects of stigma, depression, and loneliness (Ramirez-Valles et al., 2005). Other studies have shown that strong attachment to the gay community is protective for health (Li et al., 2015; Ramirez-Valles et al., 2002; Rosario et al., 2001). It offers protection by providing a sense of community and an opportunity to build social connections and systems of support that help combat loneliness. However, another study with Black MSM revealed that most of these men's social support networks were comprised of family members or non-gay friends. Furthermore, social support as an element of resilience was experienced differently among Black MSM who did not have strong connections with the gay community compared to those who did (Buttram, 2015). While previous studies among MSM demonstrate the protective effect of resiliencies on health, the results of these studies were not specific to older MSM and all of the studies were cross-sectional. More information is needed on the effects of resiliencies on health in this sub-population of MSM.
In studies that examine older lesbian, gay, and bisexual (LGB) adults, social environmental factors were found to influence the level of loneliness. In a study that investigated older LGB, primarily White (89%) adults, both those living alone and those living with someone other than a partner reported higher degrees of loneliness compared with older LGB adults living with a partner or spouse (Kim and Fredriksen-Goldsen, 2016). Results revealed that social support, social network size, and internalized stigma partially accounted for the observed relationship between living arrangement and loneliness (Kim and Fredriksen-Goldsen, 2016). Another study reported that older, mostly White, LGB adults living alone are more likely to feel lonely than those living with others (Grossman et al., 2000). Furthermore, results revealed that an elevated risk of loneliness among these adults is associated with a lower level of satisfaction with the social support they receive (Grossman et al., 2000). Existing literature suggests that the relationship between living arrangement and loneliness may be because persons in non-partnered living arrangements have limited social resources (Grossman et al., 2000; Schnittker, 2007; Yeh and Lo, 2004). These studies, while relevant to older MSM, were limited in that they mainly focused on one particular dimension of the social environment and did not focus on participants’ HIV status.
Given the dearth of longitudinal studies on loneliness among older MSM with and without HIV, this study aimed to fill this gap in the literature by examining the extent to which social environmental resiliencies—defined as an individual's level of support, social bonding, and psychological sense of community—act as protective factors against loneliness over time among these subpopulations of MSM (Fig. 1). This study had a HIV-negative MSM group that acted as a control group. The objectives of this study among older MSM with and without HIV infection were to: (1) identify underlying classes of individuals based on their social environment using longitudinal latent class analysis; (2) assess the prevalence of loneliness by these underlying classes; and (3) examine whether there are differences in the prevalence of loneliness by HIV status. We hypothesized that aging MSM who report higher levels of social support and social bonding, and a stronger psychological sense of community among gay men will be less likely to experience loneliness than aging MSM who do not. We also hypothesized that there will not be differences by HIV status. Based on the resilience literature, we predicted that the impact of social-environmental resiliencies (i.e., social support, social networks, and social cohesion) on loneliness will be greater than the impact of HIV status.
Section snippets
Study population
The Multicenter AIDS Cohort Study (MACS) is a longitudinal study that examines the natural and treated history of HIV/AIDS among men who have sex with men (MSM) in Baltimore, Maryland/Washington, DC, Chicago, Illinois, Los Angeles, California, and Pittsburgh, Pennsylvania. Since 1984, 7,352 HIV-positive and -negative participants were enrolled over four time periods: 4,954 in 1984–85, 668 in 1987–1991, 1,350 in 2001–2003, and 380 in 2011–2019. MACS participants attended semiannual visits that
Indicators of social environment
We included three scales as indicators of the latent construct of social environment among MSM: 1) perceived social support; 2) social bonding as measured by the 24-item social provisions scale (Cutrona et al., 1987; Russell and Cutrona, 1984); and 3) psychological sense of community scale adapted to the gay male community (McMillan and Chavis, 1986; Proescholdbell et al., 2006). Data from these scales were obtained at Waves 3, 4, and 5.
Perceived Social Support. Social support was defined as
Covariates
Covariates were obtained at wave 3.
HIV Status. HIV status (“HIV-positive”/“HIV-negative”) was assessed using enzyme-linked immunosorbent assay and a confirmatory Western blot on all MACS participants at their baseline visit and at every visit for HIV-negative participants. HIV-positive participants include those who tested as such at baseline or seroconverted during study observation.
Percentage of Completed MACS Visits. To assess for possible cohort effect on loneliness, we calculated the
Population characteristics by HIV status
There were 631 (50.3%) HIV-negative and 624 (49.7%) HIV-positive participants. The overall median age was 61.0 (IQR: 55.0–66.0) years (HIV-negative: 63.0 years; HIV-positive 58.0 years). The overall median percentage of completed MACS visits was 86.2% (IQR:75.0%–96.6%) (HIV-negative: 79.5%; HIV-positive: 89.7%). The majority of participants were White, non-Hispanic (HIV-negative: 80.7%; HIV-positive: 58.0%), college educated (HIV-negative: 90.3%; HIV-positive: 81.4%), gay (HIV-negative: 89.2%;
Discussion
Our results were consistent with our original hypothesis and clearly demonstrated that the social environmental resiliencies impacted loneliness among older MSM, even after controlling for covariates and baseline loneliness. Consistent with our main hypothesis, aging MSM who reported a higher level of social support, a higher degree of social bonding, and a stronger psychological sense of community among gay men were less likely to experience loneliness than aging MSM who did not. To our
Conclusions
The current study offers evidence for the theoretical and practical significance of social-environmental resiliencies already adopted by many aging MSM with and without HIV to protect against loneliness. These findings can inform the development of potentially efficacious interventions to diminish loneliness among aging MSM. Older MSM are a unique and vulnerable, yet resilient population; leveraging social-environmental resiliencies is key to reducing loneliness and promoting health in this
Credit statement
Conceptualization: MDJ and MWP; Methodology: MDJ, DW, and MWP; Formal analysis: MDJ, DW, and MWP; writing—original draft preparation: MDJ and DW; writing—review & editing: MDJ, DW, ALB, JEE, SAH, FJP, RD, MRF, and MWP; Visualization: MDJ and DW.
Acknowledgments
This study is funded by the National Institute for Minority Health Disparities [grant R01 MD010680 Plankey & Friedman]. The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). MWCCS (Principal Investigators): Atlanta CRS (Ighovwerha Ofotokun, Anandi Sheth, and Gina Wingood), U01-HL146241; Baltimore CRS (Todd Brown and Joseph Margolick), U01-HL146201; Bronx CRS (Kathryn Anastos and Anjali
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