A Model of Suicidal Ideation in Adults Aging With HIV

A Model of Suicidal Ideation in Adults Aging With HIV David E. Vance, PhD, MGS Linda Moneyham, DNS, RN, FAAN Pam Fordham, PhD, RN Thomas C. Struzick, MSW/ACSW, LCSW, MEd Continuing advances in antiretroviral therapy are increasing survival and longevity for people living with HIV. However, factors related to depression and suicidal ideation associated with aging and HIV may mean that the synergistic effects of aging with HIV could place many adults at undue risk for these conditions. Such factors include ageism and stigma, loneliness/decreased social support, neurological changes, declining health, fatigue, changes in appearance, and financial distress. Potential interventions that address these factors are needed to abate depression and prevent suicidal ideation. Nurses are in key positions to identify and intervene with HIV-infected and aging patients who may be at risk for depression and suicidal ideation. Key words: aging, AIDS, depression, fatigue, finances, HIV, lipodystrophy, suicidal ideation

In 2005 in the United States, the number of people living with HIV infection (PLWH) aged 50 and older has grown dramatically. This group of older adults comprises 15% of all new HIV/AIDS diagnoses, 24% of PLWH, 29% of persons living with AIDS, and 35% of AIDS-related deaths (Centers for Disease Control and Prevention [CDC], 2008). The number of older adults with HIV is expected to continue to rise because of three factors. First, combination antiretroviral therapy (ART) has been shown to be effective in reducing the amount of virus in the blood, allowing greater numbers of CD41 lymphocyte cells to remain

viable to fight off infection. Protecting the immune system in this manner prevents HIV from progressing to AIDS and increases the life span of PLWH (Perez & Moore, 2003). Second, later-life infections are more common than previously thought, with 15% of all new cases of HIV infection occurring in adults 50 years and older (CDC, 2008). Later-life infections may be a consequence of several factors including healthier lifestyles and greater mobility creating opportunities for more sexual engagement, less perceived risk of sexually transmitted diseases in older adults, and thinner genital and vaginal membranes accompanying physical aging, which may promote membrane ruptures during sex and provide an opening for transmission of the virus (Coleman, 2006). Finally, with the number of older adults increasing in general, the number of older adults with HIV will

David E. Vance, PhD, MGS, is assistant professor, School of Nursing, University of Alabama at Birmingham. Linda Moneyham, DNS, RN, FAAN, is professor and Rachel Z. Booth Endowed Chair, School of Nursing, University of Alabama at Birmingham. Pam Fordham, PhD, RN, is assistant professor and chair, family/child health and caregiving project director, palliative care nurse practitioner program, School of Nursing, University of Alabama at Birmingham. Thomas C. Struzick, MSW/ACSW, LCSW, MEd, is associate director, Community Health Resource Development Core Center for the Study of Community Health, School of Public Health, University of Alabama at Birmingham.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 19, No. 5, September/October 2008, 375-384 doi:10.1016/j.jana.2008.04.011 Copyright Ó 2008 Association of Nurses in AIDS Care

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shadow such unprecedented aging (Vance & Robinson, 2004). With unprecedented growth in this unique population, the challenges that older adults with HIV face remain largely unexplored. Whereas the use of ART has increased the rate of survival of patients with HIV, this increased survival rate has introduced additional drug-related as well as age-related symptoms that may compromise quality of life. By combining and extrapolating both the gerontology and HIV literatures, the authors propose that, for those aging with HIV, depression, and in its more severe form, suicidal ideation, may be particularly problematic. In fact, many of the correlates of depression and suicidal ideation in HIV are also reported with aging. Thus, the authors posit that aging with HIV may place some individuals at particular risk for depression and suicidal ideation (Vance & Robinson, 2004). The purpose of this article is to synthesize the HIV and gerontology literatures by providing a model of the factors contributing to depression and suicidal ideation in adults aging with this disease (see Figure 1). Such factors include ageism and HIV-related stigma, loneliness/decreased social support, neurological changes, declining health, fatigue, changes in appearance, and financial distress. Although no formulaic review of the literature was conducted, this synthesis was based on interpretation of the literature as well as on clinical and research experience in HIV from nursing (Moneyham & Fordham), geropsychology (Vance), and social work (Struzick). As a synthesis of the literature, articles were selected based on their relevance to the conceptual definitions of depression and suicidal ideation as related to this clinical population. Depression was defined as negative affect expressed as hopelessness or sadness that diminishes quality of life. Suicidal ideation was defined as continued contemplation about ending one’s life to escape feelings of hopelessness and sadness. The importance of this topic lies in the fact that depression and suicidal ideation negatively affect one’s ability to age successfully. Fortunately, nurses have direct contact with patients who are aging with HIV and can identify those who are at risk and intervene to improve the quality of life. This article provides a model that can serve as a guide for prevention and intervention.

Loneliness/Decreased Social Support

Ageism

Stigma

Loneliness/Decreased Social Support Neurological Changes

Neurological Changes

Declining Health

AGING

AGING WITH HIV

Declining Health

HIV

Fatigue

Fatigue

Changes in Appearance

Changes in Appearance Financial Distress

Financial Distress

Increase in Depressive Symptomatology Increase in Suicidal Ideation Increase in Suicide Rate

Figure 1. The influence of aging, the influence of HIV, and potential combined effects.

Suicidal Ideation in HIV Given the stressful and complex physical and social influences of being diagnosed with a stigmatizing disease such as HIV, finding depression and suicide rates that are much higher in this population compared with the general population and in other chronic conditions is not surprising (Moneyham et al., 2005). In a meta-analysis examining major depressive disorders, Ciesla and Roberts (2001) reported that adults with HIV were twice as likely to be depressed compared with uninfected samples. Feelings of hopelessness, lack of control, and loss of future self are common in the HIV population. These feelings frequently manifest as depression and suicidal ideation. Before the advent of ART, a diagnosis of HIV meant a slow, often painful, death. At that time the suicide rate of gay male New Yorkers with HIV was 35 times higher than that of the general population (Joseph et al., 1990). ART introduced hope back into the community of PLWH. Despite such optimism, HIV remains a serious disease characterized by stigma, personal regrets, financial worries, medical complications, disfigurement caused by ART-related lipodystrophy, and concerns about sexual intimacy (Vance & Robinson, 2004). The complexity of these issues places considerable strain on individuals, often overwhelming coping mechanisms and resources, making them vulnerable to depression and suicidal ideation.

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Depression and suicidal ideation occur more often after the initial diagnosis of HIV and when individuals experience health problems and become symptomatic (Carrico et al., 2007). For example, in a sample of 207 female New Yorkers with HIV, Cooperman and Simoni (2005) reported that 26% attempted suicide after their diagnosis. Of those who attempted suicide, 27% tried within the first week after diagnosis and 42% tried within the first month. With the passage of time, most individuals learn to cope with their diagnosis. Evidence suggests, however, that when adults with HIVexperience symptoms of HIV-related illnesses, depression and suicidal ideation return (Carrico et al., 2007). Although depression and suicidal ideation are commonly experienced in response to the diagnosis of HIV and the onset of AIDS, the lifetime and current incidence of suicidal ideation remains high. In a sample of 2,909 adults with HIV, Carrico et al. (2007) reported that approximately one fifth (19%) of the sample reported having thoughts of suicide within the previous week. In a sample of 246 nonpsychiatric adults with HIV, Robertson, Parsons, van der Horst, and Hall (2006) reported that nearly two thirds had suicidal ideation at some point in their lives. The prevalence of such high rates of suicidal ideation indicates that the stressors associated with HIV are severe enough to have an impact on the quality of life in this population. These high rates during all stages of HIV suggest that other factors are involved.

Suicidal Ideation in Aging Despite the fact that many people who age successfully perceive an enriched quality of life, some individuals find aging more difficult. Understandably, aging marks a time of loss of close friends and family, health and physical functioning, financial productivity, energy, physical appearance, and mental sharpness. These cumulative experiences can stress internal and external resources and coping mechanisms that lead to depression (Alexopoulos, 2005). Depression and dysthymic disorders affect 5% to 10% of older adults (Lyness, Caine, King, Cox, & Yoedinono, 1999), which can intensify the propensity for suicidal ideation (Fairweather, Anstey, Rodgers, Jorm, & Christensen, 2007). These rates are likely

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to be significantly higher because depression is often underdiagnosed. Normally, suicidal ideation precedes attempted and completed suicides (Conwell & Duberstein, 2001). Hirsch, Duberstein, Chapman, and Lyness (2007) observed that 8% of the older population in general reported some degree of suicidal ideation; this figure was 17% lower than the most conservative rate of suicidal ideation reported in older adults with HIV (Nichols et al., 2002). This result is further reflected in suicide rates that rise with age, especially for men. Men 65 to 69 years old have a suicide rate of 21 per 100,000. This rate continues to rise to 32 per 100,000 and 48 per 100,000 for men 75 to 79 years old and 85 years and older respectively, which is twice that of men between 16 to 65 years old. Concomitantly, adults 65 years and older account for 18% of all suicide deaths but make up only 13% of the U.S. population (National Center for Health Statistics, 2004). The elevated suicide rate in older adults seems to be contradictory to other results on resilience and decision making in this population. Carstensen, Fung, and Charles (2003) suggested that over their lifetime, older adults become more skilled in their decision making to seek out positive experiences and personal interactions while actively avoiding situations that evoke negative affect. Despite enhanced decision making, suicide rates of older adults remain high. Perhaps the increasing occurrences of situations that are out of an older person’s personal control overwhelm individuals, and this increases the vulnerability to depression and suicidal ideation.

Suicidal Ideation in Aging and HIV Very few studies have examined depression and suicidal ideation in older adults with HIV despite known elevated rates associated with both aging and HIV. Despite this gap in the literature, two studies have documented this phenomenon in older adults with HIV. In a sample of 172 older adults with HIV (85% 45-59 years old, 15% 60 years old or older), Nichols et al. (2002) reported that 25% of their sample attempted suicide at some point during their lives, with 17% of the sample indicating that they had wanted to commit suicide within the 6 months before

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their interviews. Of this 17%, 38% of the participants indicated that taking pills was the preferred method of committing suicide. The fact that they had considered the means of suicide underscored the severity of such ideation. Similarly, in a sample of 113 older adults with HIV (M age 5 53.4 years), Kalichman, Heckman, Kochman, Sikkema, and Bergholte (2000) reported 27% indicated that they thought about taking their life within the previous week. Participants who self-identified as gay and White were significantly more likely to report suicidal ideation. However, in the authors’ model (see Figure 1), other factors particularly germane to aging and HIV may also act singularly or in tandem to contribute to this high rate. These factors include ageism and stigma, loneliness/decreased social support, neurological changes, declining health, fatigue, changes in appearance, and financial distress. Ageism and Stigma Stigmas associated with age (i.e., ageism) and HIV stigma are social phenomena that place many at a social and psychological disadvantage. With ageism, one may not be considered by oneself or others as attractive, productive, or valued. Likewise, with HIV stigma, values such as being morally unfit, a diseased pariah, and unwanted by society may be attached to the individual’s sense of self. Aging combined with HIV places many at risk of acute social stigma (Vance & Robinson, 2004). People of color, women, and those living in poverty may be further stigmatized. Thus, combined stigma may place undue stress on personal coping mechanisms; similarly, internalized stigma may also compromise resiliency in aging with this disease. Nichols et al. (2002) conducted a mixed-methods approach with 172 older adults who had HIV and reported that the combination of ageism and HIV stigma represented a barrier that kept some older adults from seeking the support they needed from family and friends, religious institutions, and the larger community. As many older adults expressed in the qualitative part of the study, health professionals often did not consider older patients as sexual beings and at risk for HIV or other sexually transmitted diseases. This view was further compounded by the fact that most HIV prevention and social service

media information used younger models in health promotion messages and programs; older adults were intentionally or unintentionally left out of such advertisements. Likewise, many older adults who disclosed their HIV status reported feeling that social service and health professionals treated them with disdain, as if the patient should have known better than to contract HIV at their age. Thus, Nichols et al. (2002) remarked that such real and perceived stigma could lead to social isolation resulting in depression and suicidal ideation. Loneliness/Decreased Social Support Loneliness and declines in social support associated with aging and HIV may contribute to depression and suicidal ideation. In a sample of 160 New Yorkers with HIV who were over 50 years old, Shippy and Karpiak (2005) reported that 71% were living alone, and only 47% reported being in a committed relationship. This sample’s major source of support came from friends who were also infected with HIV. Although depending on others with HIV would seem to bond people together through shared interests and experiences, 57% indicated that their emotional needs remained unfulfilled. Unmet emotional needs and feelings of isolation may exceed the individual’s coping mechanisms, contributing to depression and suicidal ideation. Shippy and Karpiak (2005) also reported that 58% of the sample were depressed. Carrico et al. (2007) reported that elevated depressive symptomatology was a risk factor for suicidal ideation, along with being homosexual/bisexual/transgendered and not being in a romantic relationship. These results suggested that aging PLWH were doing so without traditional informal supports such as partners and family members who could provide social and emotional care. Because loneliness tends to increase with age (Hawkley & Cacioppo, 2007), those aging with HIV may be particularly at risk for fragile social networks and social isolation. Neurological Changes Neurological changes that occur with aging and HIV may further contribute to the risk of depression and suicidal ideation. Subcortical regions of the brain may be particularly compromised by the combination of aging

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with HIV. The substantia nigra and basal ganglia have been shown to be sensitive to the effects of normal aging and HIV. In nonpathological aging, the number of pigmented neurons of the substantia nigra declines quickly starting in the 40s and 50s, so that by age 65 there is a cumulative loss of approximately 35% of neurons. Likewise in nonpathological aging, the number of dopamine (D1) receptor binding sites in the basal ganglia decreases by 6.9% per decade (Powers, 2000). In fact, the basal ganglia is more sensitive to the effects of aging than the brain as a whole (Murphy, DeCarli, Schapiro, Rapoport, & Horowitz, 1992). Declines in both neural substrates can also be exacerbated by the presence of disease (Powers, 2000). The nervous system is the most impaired system in HIV after the immune systems (Williams & Hickey, 2002). In HIV, damage to the substantia nigra (Nath et al., 2000) and the basal ganglia (Aylward et al., 1993) is even more pronounced (Vance, 2004). Thus, someone aging with HIV is at risk for developing cumulative damage to these neural substrates. As mentioned, the presence of other diseases may accelerate such loss; however, illicit substance use has also been shown to result in damage to these neural substrates (Melega, Lacan, Harvey, & Way, 2007). Furthermore, substance use such as alcohol abuse has been associated with suicidal behavior (Brady, 2006). This point about substance use is particularly important given the history of drug use in some PLWH (Grassi et al., 1995). Problems with these neural substrates are responsible for psychomotor difficulties as seen in Parkinsonism (not to be confused with pathological aging as seen in Parkinson’s disease). These neural substrates also affect the ability to initiate action or thought and regulate mood, and they increase perseveration difficulties (Koutsilieri, Sopper, Scheller, ter Meulen, & Riederer, 2002; Vance, 2004). Perseveration is a neuropsychological term indicating a repetitive pattern of thinking or behaving in which it is difficult to break out of an old pattern and initiate a new one (Lezak, 1995; Vance, 2004). Emotional difficulties along with the tendency for perseveration may accentuate the ability to think about problems while impairing the ability to think about anything else. In fact, Fairweather et al. (2007) reported that adults who have a ruminative personality style are more likely to contemplate suicide. Illicit substance use, as well as poly-

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pharmacy, which is more common in older adults and those on ART (Vance, Woodley, & Burrage, 2007), may also contribute to this neurological predisposition, thus further preventing adults aging with HIV from using their full cognitive resources to cope with their problems. For example, Carrico et al. (2007) reported that more self-reported habitual use of marijuana was a significant risk factor for suicidal ideation. Therefore, providing resources for continued cognitive functioning may help older adults age successfully with HIV (Vance & Burrage, 2006). Declining Health Age-related losses, especially declines in physical functioning and health, can contribute to depression and suicidal ideation. In a large sample of adults with HIV, Carrico et al. (2007) reported that those who self-rated their medication side effects and HIV-related symptoms as being severe were significantly more likely to report suicidal ideation. Likewise, in a sample of older adults with HIV, Kalichman, Difonzo, Austin, Luke, and Rompa (2002) reported that a very low CD41 lymphocyte count, a detectable or high viral load, and medical side effects of ART were all significantly associated with suicidal ideation. It is also worth mentioning that physical health problems that accompany aging such as pulmonary disease and chronic pain have been associated with elevated levels of suicidal ideation (Goodwin, Kroenke, Hoven, & Spitzer, 2003; Heisel & Flett, 2006; Ratcliffe, Enns, Belik, & Sareen, 2008). This result is an important consideration given that many adults aging with HIV will also experience other comorbidities besides HIV. Fatigue Metabolic and hormonal changes occurring with aging and HIV may result in fatigue and accentuate depression and suicidal ideation. Aging with HIV may place a PLWH at risk for mitochondrial dysfunction. Mitochondria are cellular organelles responsible for energy and metabolism. With aging, mitochondrial DNA (mtDNA) replicates itself less efficiently because of mutations, which results in decreased energy production (Brierley Johnson, James, & Turnbull, 1996). Systematically, this reduces energy for

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the entire body. In fact, the Mitochondrial Theory of Aging posits that it is the decline of such energy that creates the physiological processes of aging (Ozawa, 1998). With HIV, nucleoside reverse transcriptase inhibitors (NRTIs) can reduce mtDNA, producing fewer mtDNA-encoded mitochondrial enzymes and altering energy production (Medina, Tsai, Hsiung, & Cheng, 1994). As a result, aging with HIV, coupled with long-term exposure to NRTIs, may place many PLWH at risk for mitochondrial dysfunction and subsequent fatigue. Such fatigue has been associated with depression in HIV (Arendt, 2006). Furthermore, Segerstrom (2007) proposed an interesting hypothesis based on results that the immune system is an energetically costly system. To maintain immune function, especially during periods of prolonged stress, energy allocated for psychosocial health, such as maintaining optimism, may be redirected. Segerstrom posited that this is why several studies have shown an inverse relationship between poor immunity and optimism. Considering this position for someone aging with HIV who is experiencing prolonged periods of chronic disease and stress, this energy transfer to boost the immune system may predispose PLWH to fatigue and poor psychosocial outcomes that may result in depression. Changes in Appearance Changes in appearance accompany aging, and some adults have difficulty with this transition. For those aging with HIV, such changes can be dramatic because of side effects of ART, including lipodystrophy. Lipodystrophy, a disfiguring of the arms, legs, abdomen, upper back, and face caused by fat redistribution in the body, occurs naturally with aging and more dramatically in many PLWH who are taking ART (Esch, 2006). Such visual disfigurement, especially in conjunction with aging, can be devastating to an individual’s self-esteem and sense of worth, creating social and sexual problems that can result in demoralization, depression, and suicidal ideation (Collins, Wagner, & Walmsley, 2000; Sharon, 2004). Nichols et al. (2002) described one older participant in their study who despite her best efforts felt disgusted with her appearance and blamed HIV for those changes. Fortunately, treatments such as collagen products, hyaluronic acid, calcium hydroxylapa-

tite, and poly-L-Lactic acid are effective in at least temporarily returning the face to its more normal appearance (Esch, 2006). Financial Distress Obviously, declines in health, energy, and physical appearance coupled with ageism and HIV stigma can negatively affect productivity and earning potential. Steffens (2007) suggested that the loss of productivity in older adults could contribute to depression and suicidal ideation. Fairweather et al. (2007) reported that older adults who were seeking employment were nearly seven times more likely to have contemplated suicide within the previous year. Although they did not have the data to examine this, the researchers hypothesized that this effect might have been because of financial distress from difficulties competing with younger job seekers (Stack, 2000). Financial pressures may be more extreme in older adults with HIV. For example, Nichols et al. (2002) reported that 63% of their sample of older adults with HIV indicated that ‘‘having enough money to live on’’ was ranked as the number one greatest difficulty of living with HIV. Before ART, many individuals required private, state, and federal income assistance and pensions for extended periods to compensate for their inability to work. However, as advances in ART were introduced, the health of many PLWH improved substantially and they were required to reenter the work force even though fatigue and medication side effects affected their job performances (Brooks & Kosinski, 1999). This situation may now be even more pronounced for older PLWH who are reentering the work force, because they are faced with the painful observation that their same-age peers without HIV are nearing retirement. Because of prior low expectations for survival coupled with a series of financial crises, older PLWH may see the possibility of a comfortable retirement fading away. Moreover, with patchy work histories and limited career development because of illness, outdated job skills, and ageist attitudes, many older PLWH may be poorly situated to generate a satisfactory income to support retirement initiatives (Vance & Robinson, 2004). Clearly, such financial distress can exacerbate depression and suicidal ideation.

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Interrelationships Obviously, each of the factors that contribute to depression and suicidal ideation can interact and accentuate the effect on depression and suicidal ideation. For example, fatigue and declines in health can alter neurological health and cognitive reserves (Vance & Burrage, 2006). Such neurological changes can result in fewer cognitive resources to address the depression caused by these factors. Likewise, Vance, Wadley, Ball, Roenker, and Rizzo (2005) reported that depressive symptoms could negatively affect cognitive functioning. As such, those who experience depression may as a result also experience cognitive disruptions. In fact, Kalinin (2007) reported that cognitive impairment in some clinical populations was a risk factor for suicidality. Consequently, cognitive resources needed to confront these stress factors may be further compromised, making patients even more susceptible to depression and suicidal ideation. Thus, the model (Figure 1) serves as a tool to guide clinicians and researchers in understanding the factors that contribute to depression and suicidal ideation in older PLWH; however, it is important to mention that an endless variety of interrelationships can occur between these factors that may further aggravate the situation.

Model Summary This model serves as a representation of pertinent factors associated with aging and HIV that are stressful and can contribute to depressive symptomatology, suicidal ideation, and suicide. Figure 1 shows the unique influence of aging (on the left) and the unique influence of HIV (on the right), which overlap to indicate the combined influence of each set of factors associated with both aging and HIV. From this overlap, it is posited that the synergy of the factors associated with the aging with HIV process may place such adults at risk for increased levels of depressive symptoms, suicidal ideation, and suicide. As presented, if the factors that contribute to these detrimental outcomes are addressed, such as increasing social supports and managing fatigue, then perhaps some of the pressure that leads to depression and suicidal ideation can be reduced. However, a caveat of this model bears mentioning; the phenomenon of aging with HIV is still

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relatively new, and other factors may emerge that also contribute to this process. Thus, the factors presented here (e.g., ageism, stigma, financial distress) are by no means exhaustive; albeit, collectively they do provide a general framework in which to conceptualize and continue research in this area.

Prevention and Intervention Prevention efforts are needed to thwart the negative synergistic effects of aging and HIV that may lead to depression and suicidal ideation. On a macro level, public policy and laws make it illegal to discriminate against someone who is older or who has HIV. However on a micro level, reality is such that normal human interactions do not lend themselves easily to the rule of law. Using this model, nurses must be aware of the signs of depression and suicidal ideation (i.e., loss of previous interests, insomnia, substance use) so that they can make the best referrals for patients, whether these be for health education, counseling, antidepressants, or a combination of such treatments. (For more information see Szanto et al., 2002). Interventions must address complex personal and social issues such as loneliness, neurological changes, declines in health, fatigue, changes in appearance, and financial distress, some which can be treated medically. Although an intervention will not address all of these stressors, targeting at least one or two factors contributing to depression may provide some relief for the individual aging with HIV so that his or her existing coping mechanisms can reassert themselves.

Conclusion Depression and suicidal ideation represent significant problems for many older adults, especially those living with HIV. Logically, those who are aging with HIV may be particularly vulnerable to these influences. Ageism and stigma, loneliness/decreased social support, neurological changes, declining health, fatigue, changes in appearance, and financial distress represent some of the major factors that contribute to this phenomenon; however, this list is by no means exhaustive. Depression and suicidal ideation will continue to be elusive conditions, many times difficult to detect and to treat. In fact, although active suicide (such as through

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an inflicted gunshot wound) is easily documented, passive suicide (such as through medication noncompliance or substance use) must also be considered. By understanding at least some of the factors that may cause such negative affect, nurse clinicians and nurse researchers can intervene and develop better means to care for these individuals and to enhance their abilities to age successfully with HIV.

Clinical Considerations  When working with adults aging with HIV, it is important to realize that this growing segment of the population will more likely be vulnerable for depression, and in more extreme forms, suicidal ideation.  Similar factors that contribute to depression and suicidal ideation in older adults are also present in PLWH; thus, such factors place many older adults with HIV at risk of depression and suicidal ideation.  Social stigma (ageism, HIV stigma), loneliness/ decreased social support, neurological changes, declining health, fatigue, changes in appearance, and financial distress add to the stress contributing to depression and suicidal ideation.  Each of these stressors must be addressed when examining ways to mitigate the role of depression and suicidal ideation in adults aging with HIV.  In particular, neurological changes that occur with aging and HIV may predispose PLWH to perseverate on negative thoughts and moods, contributing to depression and suicidal ideation.  Such negative affect hinders the ability to negotiate everyday circumstances that interfere with successful aging.  Nurses are in key positions to observe depressive symptoms and intervene. Likewise, nurse researchers will be able to examine methods to help older PLWH age successfully.

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