Impact of isolation and loneliness on older people living with HIV
Maille Karris from the University of California, San Diego presented a talk on loneliness and social isolation as factors in ageing that included a review linking the pathogenesis of loneliness to poorer clinical outcomes. 
While social isolation is easy to define by the degree an individual connects with society, loneliness is a more complex outcome of the difference between someone’s preferred and actual relationship with other people. Being alone is not the same as feeling alone and many people enjoy being on their own without feeling lonely. But while solitude can be positive, loneliness, even though very common, is significantly linked to poorer health.
Large national surveys have defined epidemic levels of loneliness in the US. Longitudinal surveys over decades have reported that almost half of Americans either sometimes or always felt alone or left out and that a quarter rarely or never feel that there are people who really understand them. Social networks have also become smaller with increasing numbers of people (from 10% in 1985 to 18% in 2018) having no significant person that they discuss important matters with. 
In the context of ageing, loneliness also differs by whether this is occurring during adolescence, middle age or in older age, with other differences by demographics including race and gender. Numerous studies have included having closer social networks and not living alone as reducing the risks of being lonely.
Being HIV positive can compound issues of loneliness in many long-term survivors through a history of losing friends and partners – and HIV positive people at all stages can be affected by the social effects of stigma and discrimination limiting the size of their social networks and increasing the risk of social isolation.
A large meta-analysis of studies in the general population reported strong associations between social isolation and higher rates of mortality that were consistent across gender, length of follow-up, and geographical region. It reported that social isolation, loneliness and living alone were associated with 29%, 26%, and 32% increased likelihood of mortality, respectively.  Some of the same research group, again in large meta-analysis, reported that people with larger social networks have higher survival outcomes. 
Smaller surveys have reported higher levels of loneliness (~60%) in people living with HIV, and more negative health outcomes, including a greater likelihood of smoking, at-risk drinking or substance use, higher rates or depression and lower quality of life.  Higher rates of isolation are especially linked to higher rates of depression.
From a public health perspective, people who are socially isolated have higher medical costs: with a US study reporting higher Medicaid costs of $134/month ($6.7 billion annually), driven by cardiovascular disease and stroke. 
The pathogenesis of clinical symptoms of loneliness was shown to be moderating health through stress-induced cortisol dysregulation, higher rates of inflammation, higher levels of viral activity (EBV and HHV8) and poorer immune responses (including to influenza vaccine). Induced stress tests were also reported to increase some proinflammatory cytokines, including IL-6. 
Other factors associated with loneliness in a study of almost 1000 HIV positive people, included not being in a relationship, lower financial income, poorer adherence, living alone, higher risk of smoking and comorbidities (including frailty, cognitive decline and depression) and lower quality of life. 
Practical ways for managing loneliness include psychosocial therapy, befriending interventions and supporting leisure skill and activities. In the US this has included a novel village model of community living where networks of friends contribute membership costs towards shared resources to support needs as they age as a group. The needs of communal villages enable people to live independently as they age but are likely to be easier when people are well (and by definition likely wealthy). A current example that hopes to overcome some of the challenges of sustainability has linked an initiative for older HIV positive people in San Diego to the local LGBT centre.
This project, currently being evaluated, includes a local social media app and network to identify and meet needs for the group that includes quality of life as a primary outcome.
Poor medical outcomes associated with higher levels of social isolation that someone would ideally like, are easily impacted by HIV, but also they provide the chance for lifestyle interventions that could theoretically reverse these risks.
Very few people deliberately set out to become lonely or isolated but for many people the social challenges of living with HIV make this easier to say than do, both on individual and population levels.
This talk produced many comments from community participants who confirmed the importance of this subject in people’s real lives and asked for further research into this complex aspect of living with HIV.
An easy suggestion for doctors is just to ask their patients if they are lonely.
- Karris MY. My shadow’s the only one that walks beside me: Loneliness and social isolation in Older PLWH. 10 International Workshop on HIV and Ageing, 8-9 September 2019, New York.
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- Holt-Lunstad J et al, Social relationships and mortality risk: a meta-analytic review. PLoS Med 7(7): e1000316.
- Greene M et al. Loneliness in older adults living with HIV. AIDS and Behavior 2018; 22(5):1475-1484. doi: 10.1007/s10461-017-1985-1. https://www.ncbi.nlm.nih.gov/pubmed/29151199
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- Jaremka LM et al. Loneliness Promotes Inflammation During Acute Stress. Psychological Science 2013
- Mazonson P et al. Characteristics Associated with Pre-Frailty in Older People Living with HIV. Open Forum Infectious Diseases, (6), Suppl 2: S186. doi.org/10.1093/ofid/ofz360.425. (October 2019).