An Examination of the Social Networks and Social

An Examination of the Social Networks and Social Isolation in Older and Younger Adults Living with HIV/AIDS Charles A. Emlet This study examined social networks and social isolation in older (50 years or more) and younger (ages 20 to 39) adults with HIV/AIDS. The author conducted interviews with 88 individuals living with HIV/AIDS in the Pacific Northwest. Both groups’ social networks had similar patterns; however, older adults were more likely to live alone. More than 38 percent of older adults and 54 percent of older adults of color were at risk of social isolation compared with 25 percent of those 20 to 39 years of age. Older men and older adults of color had significantly lower scores on the social network scale than others. Having a confidant and receiving instrumental support were significantly correlated with reduced HIV stigma. Implications for social work practitioners are discussed. KEY WORDS: aging; HIV/AIDS; older

adults; social isolation; social networks; social support

S

ocial workers, gerontologists, and public health officials are beginning to recognize the impact of HIV/AIDS on older adults. Because HIV/AIDS is seen primarily as a disease of younger people, older adults with HIV disease have been referred to as a hidden population (Emlet, 1997) and as the “invisible ten percent” (Genke, 2000), the latter referring to the fact that adults age 50 years and older have traditionally represented approximately 10 percent of adult AIDS cases in the United States. The advent of highly active antiretroviral therapies (HAART) in the 1990s, however, has extended life for many people with HIV disease and will allow, as never before, individuals who were infected in midlife to live into old age. The number of older adults diagnosed with HIV before age 50 has increased consistently during the 21st century and will continue to increase in numbers as treatments for HIV improve (Mack & Ory, 2003). Surveillance data from the Centers for Disease Control and Prevention (CDC, 2005) have illustrated this phenomenon: The estimated number of people 50 years and older living with HIV/AIDS increased from 65,655 in 2001 to 104,260 in 2004. This represents a 59 percent increase in four years.This pattern appears to hold true for adults on the older end of the spectrum as well.

CCC Code:/0360-7283/06 $3.00 ©2006 Associationand of Social Emlet An Examination of the National Social Networks SocialWorkers Isolation

During that same time period, the estimated number of adults 65 years and older living with HIV/AIDS rose from 6, 674 to 10,861 (an increase of more than 60 percent) (CDC). Although cases of HIV/AIDS are increasing among older adults, deaths continue to increase as well. According to CDC data, deaths from AIDS decreased by 8 percent overall between 2000 and 2004; however, they increased in all age categories 50 years and older (CDC). Because older adults continue to be diagnosed with HIV/AIDS in increasing numbers, it is imperative that we continue to improve our knowledge of issues that positively and negatively affect these individuals. This article explores the social networks of older adults living with HIV disease and compares those networks with those of their younger counterparts. This information should add to the knowledge base concerning this population, as well as elucidate for practitioners sociodemographic characteristics that may increase vulnerability for social isolation. THE IMPORTANCE OF SOCIAL NETWORKS AND SUPPORT

Social support networks have been consistently acknowledged as an important element in the lives of people with HIV/AIDS. Adequate social support

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has been associated with physiological and treatment aspects of HIV. For example, inadequate social support has been associated with lower physical functioning (Collins, 1994; Gielen, McDonnell,Wu, O’Campo, & Faden, 2001), and adequate emotional support has been found to improve compliance with HIV medications (Cox, 2002). Social support has been repeatedly associated with psychological functioning, such as psychological well-being and mental health (Catz, Gore-Felton, & McClure, 2002; Collins; Cowdery & Pesa, 2002), positive states of mind (Turner-Cobb et al., 2002), coping with the stress of the disease (Crystal & Kersting, 1998), and quality of life (Gielen et al.). Although the importance of social support to adults with HIV disease has received considerable attention, Shippy and Karpiak (2005) pointed out that most studies have focused on younger gay white men. In fact, many studies that have examined social support in HIV-infected populations did not collect data on age or neglected age as a variable in their analysis (Catz et al.; Cox; Crystal & Kersting, 1998; Gielen et al.; Pakenham, 1998; Turner-Cobb et al.). A small number of studies have examined various elements of social support among midlife or older adults living with HIV/AIDS. Although not focusing on older adults specifically, Cowdery and Pesa’s (2002) study included both older and younger adults who had HIV and analyzed age as an independent variable. They found increased age to be significantly associated with lower levels of social functioning. Schrimshaw and Siegel (2003) studied 63 adults, age 50 years and older, living with HIV/AIDS. Forty-two percent of their participants felt their emotional support was inadequate to meet their needs, and 27 percent stated that they did not receive enough practical assistance. Reasons for insufficient support included the unavailability of family and the deaths of friends. Heckman and colleagues (2002) examined social support as part of their chronic illness, quality-of-life model in 83 people ages 50 and older with HIV/AIDS. They found that those older adults who experienced barriers to health and social services also reported lower perceptions of social support and increased depressive symptoms. In another study, Heckman and colleagues (2000) examined the influence of race on coping, social support, and psychological distress among 72 midlife and older men. They found that African American men received significantly more support from immediate family

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members than their white counterparts but were less likely to disclose their HIV status to friends. A recent study by Shippy and Karpiak (2005) found that 57 of 100 older adults with HIV/AIDS felt the emotional support available to them was inadequate, and 78 percent stated they needed more instrumental support.They also found that women were more likely than men to report adequate social support. These studies have helped to increase our knowledge about older adults’ views on their perceived social needs as well as how social support affects psychological functioning. CONCEPTUAL FRAMEWORK

One important question related to social support is whether the social networks of HIV-infected individuals change with age. For example, multiple studies have shown that older adults with HIV/AIDS are more likely to live alone than their younger counterparts (Crystal et al., 2003; Crystal & Sambamoorthi, 1998; Emlet & Berghuis, 2002; Emlet & Farkas, 2002). The concept that social networks change over time is consistent with the convoy theory of social support (Antonucci & Depner, 1982; Kahn & Antonucci, 1980), in which social support networks are seen to evolve over time as people’s needs and circumstances change. This change occurs as people move through the life course.With aging, for example, network members are lost through mortality or other events (Antonucci & Depner). Kahn and Antonucci suggested that various determinants go into making one’s convoy of social support, including properties of the person (for example, age and other demographic characteristics) and properties of the situation (that is, role expectations, resources, and demands). The convoy can be constructed from a variety of sources, including family, friends, and others, and can at any given time be influenced by specific events, circumstances, and people (Antonucci & Knipscheer, 1990). If we are to learn how the social networks of individuals living with HIV/AIDS change over time, we can neither ignore age as a variable in studies of social support nor look at older adults in isolation from other age groups. We must consider the importance of a life-course perspective. To provide some comparison of the social networks of older and younger adults living with HIV/AIDS, I undertook an exploratory, cross-sectional study that addressed three basic questions:

Health & Social Work Volume 31, Number 4 November 2006

1. What are the major components (sources) of the social networks of younger and older adults with HIV/AIDS? 2. What influence do age, gender, race, and sexual orientation have on one’s support network and risk of social isolation? 3. Are there elements of one’s social network (size, source, and role) that will help mitigate the effects of HIV stigma?

METHOD

Participants and Procedures

Interviews of all participants were conducted during 2002–2003 in collaboration with an AIDS service organization in the Pacific Northwest. According to agency data (Pierce County AIDS Foundation, 2002) , 12.3 percent of unduplicated clients from this agency were age 50 years and older, approximating the percentage of older adults living with AIDS found in national statistics as well as in Washington State. As part of the cooperative research agreement, case managers from the AIDS service organization notified clients (both active and inactive) in the agency database who were age 50 and older of the opportunity to participate in this study. Because of the relatively small number of individuals in this age group living with HIV disease, purposive sampling techniques were used. A comparison sample was developed using a matched case control design. Each older adult was matched, as closely as possible, on gender, ethnicity, HIV transmission route, and diagnosis with an individual between the ages of 20 and 39 years. An age barrier (39 to 50 years) was created to avoid any artificial distinctions that may be made when comparing participants younger than and older than 50. Although sampling without an age barrier is often used to compare age groups in HIV research, actual differences between a 49-year-old and a 51-year-old may have little actual meaning. During the initial contact with respondents, the study was briefly described; for those interested in participating, an appointment was made for a face-to-face interview with the principal investigator or a research assistant. At that appointment, the study was described in detail, and those who wished to participate signed the informed consent form. Structured interviews lasted 45 minutes to one hour. The university institutional review board approved all procedures. At the completion of the interview, participants

were provided $25.00 in cash for their time and assistance. Measures

During the interview, participants answered questions related to sociodemographic characteristics, including age, gender, race and ethnicity, education, income, employment status, Medicaid eligibility, and HIV diagnosis (HIV versus AIDS). Participants also completed the 18-item Lubben Social Network Scale (LSNS-18) (Lubben & Gironda, 2003) and a 13-item HIV stigma scale.The LSNS was originally published as a 10-item scale for examining social isolation (Lubben, 1988; Levine, 2000).The 18-item version used in this study “increased quantification of key structural and functional elements” (Lubben & Gironda, p. 331).This version disaggregates three subscales for friends, family, and neighbors and has the highest level of internal consistency (α = .82) of the three available versions of the LSNS (Lubben & Gironda). The LSNS-18 is computed by summing 18 equally weighted items with scores ranging from 0 to 90. Lower scores indicate smaller networks (Lubben, Lee, & Gironda, 2000).The three subscales have summated scores that range from 0 to 30. In addition to the 18 items, one item from each subscale that identified a confidant and one item from each subscale that identified the availability of instrumental support were computed separately to identify emotional and instrumental support. These two additional measures were computed not into the total LSNS-18 score but as part of the three subscales. The 13-item HIV stigma scale was developed by Sowell and colleagues (1997) and was designed to determine how often individuals have thoughts and feelings of being stigmatized or put in jeopardy because of their illness. It uses a four-point Likerttype scale, ranging from 1 = not at all to 4 = often and provides a summated score ranging from 13 to 52, with higher scores reflecting greater stigma. The scale showed good internal consistency in this study (α = .830). RESULTS

Sample Characteristics

The final sample consisted of 88 individuals, divided into two age groups.The 44 older individuals ranged in age from 50 to 71 years (M = 55.45, SD = 5.40). The younger comparison group ranged in age from 21 to 39 years (M = 34.66, SD = 4.0). Because of

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comparison group matching, the samples differed little by race, ethnicity, or gender (Table 1). Those older than 50 were significantly more likely to live alone than their younger counterparts [χ2(2, N = 88) = 9.14, p < .01]. The younger group was more likely to have been never married than were the older group [χ2(2, N = 88) = 8.44, p < .05]. Both groups had average educational levels slightly higher than the completion of high school. Although similar proportions of both populations were working either full-time or part-time, those older than 50 were, not surprisingly, more likely to indicate they were retired because of either disability or age.Those

Table 1: Sociodemographic Characteristics of Younger and Older Adults Living with HIV/AIDS (N = 88) Variable

Mean age (SD) Male White African American Hispanic Other Living arrangement** Lives alone With family or partner Other Marital/partner status* Never married Partnered Other Education Current employment*** Unemployed Retired Works part-time or full-time Medicaid* HIV exposure Men having sex with men Heterosexual IV drug user Other HIV AIDS *p < .05. **p < .01. ***p < .001.

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Population 20–39 Years (n = 44)

50+ Years (n = 44)

34.6 (4.05) 50.8 70.5 20.5 6.8 2.3

55.4 (5.40) 49.2 70.5 20.5 6.8 2.3

18.2 61.4 20.5

47.7 43.2 9.1

38.6 38.6 22.7 12.1

20.5 27.3 52.3 13.1

75.0 6.8 18.2 77.3

23.3 51.2 25.6 52.3

50.0 36.4 11.4 2.3 25.9 74.1

38.6 43.2 11.4 6.8 29.3 70.7

in the 20-to-39-year age group were more likely to be unemployed [χ2(2, N = 87) = 27.20, p < .001] and more likely to have been on Medicaid in the past 12 months than their older counterparts [χ2(1, N = 88) = 6.02, p < .05]. Because of the matched case method, only minor differences existed in either HIV exposure or HIV compared with AIDS diagnosis. Analysis of Social Networks

The first research question sought to determine whether the components (sources) that made up the social networks of both age groups differed. The LSNS-18 provides equally weighted scoring for three sources of support—relatives, friends, and neighbors—making comparisons straightforward. By analyzing the subscores for each group, one can determine whether major differences exist between age groups. Little difference existed between age groups with regard to size and relative importance of sources of support (Figure 1). In all cases, the three subscale scores differed only slightly between the two age groups, with those 50 or older having scores one or two points lower than their younger counterparts.The relative importance of friends and relatives as opposed to neighbors was also consistent across age groups. One-sample t tests found a significant difference between mean scores for relatives and neighbors in both the younger and older age groups [ts(43) = −6.191 and −7.531, respectively, ps < .001]. Similar differences were also found in the subscale scores for friends and neighbors in both younger and older groups [ts(43) = −7.102 and −7.252, ps < .001].The main sources of support for both age groups came from relatives and friends (Figure 1). These sources contributed similarly to the overall social support network of these individuals, with neighbors playing a considerably diminished role. Gender, Sexual Orientation, and Race. The second research question sought to examine whether sociodemographic variables such as gender, sexual orientation, and race affected social networks. The social networks of older and younger adults appeared similar when examined by age alone. In an attempt to determine whether other properties of the person might influence the makeup of social networks, several analyses were conducted, focusing on gender, sexual orientation, and race. The first analysis of gender found that LSNS-18 subscale scores and total scores did not differ significantly between age


Figure 1: Comparison of 18-Item Lubben Social Network Scale (LSNS-18) Subscale Scores by Age Group 20

18

18

Mean Subscores for LSNS-18

17

16

16

16

14

12

10

9 8

8

Relative subscore Friends subscore Neighbor subscore

6 20–39 Years

50+ Years

Age Group

groups. This similarity did not hold up, however, when gender was examined along with age. Older men had consistently lower LSNS-18 scores than their younger counterparts. In the case of friends, the differences in mean scores between younger and older men were 18.71 and 15.57, respectively, and neared statistical significance (p = .80). Older men scored significantly lower on the index for instrumental help [t(59) = 2.02, p < .05], as well as total LSNS-18 score [t(59) = 2.37, p < .05].The pattern did not hold true for women. Older women had consistently higher scores across the LSNS-18 than their younger counterparts; however, the differences never reached statistical significance. It has been well documented that sexual orientation influences relationships with families of origin and that many gay and lesbian adults proclaim a family of choice (deVries & Blando, 2004). The research on sexual orientation and social support reinforces the importance of including sexual orientation in the analysis. Independent sample t tests were conducted by comparing those who

identified as gay or bisexual with those identified as heterosexual. Gay or bisexual individuals ages 20 to 39 had significantly higher scores than heterosexual individuals in the domain of friends [20.05 compared with 15.05; t(86) = –2.46, p < .05]. A similar relationship existed in the area of emotional support [7.0 compared with 4.54; t(86) = 3.22, p < .01] and the availability to receive help [7.59 compared with 4.81; t(86) = 3.55, p < .001]. Total LSNS-18 scores were also significantly greater for gay and bisexual individuals [t(86) = –2.75, p < .01]. These differences, however, were much more pronounced with the younger age group than with those 50 or older. Although older gay and bisexual individuals had lower LSNS-18 scores in most areas than their younger counterparts, the differences were not significant. In the over 50 group, the social networks of gay and bisexual individuals looked similar to those of their heterosexual counterparts (Table 2). A similar analysis was conducted using race as the independent variable. Because of the relatively small number of individuals who were not white or


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Table 2: Eighteen-Item Lubben Social Network Scale (LSNS-18) Subscore and Total Score Means by Age Group and Sexual Orientation

Ages 20–39

Scale

Age 50 or Older

Gay/ Bisexual Other

Relative subscale Friend subscale Neighbor subscale Confidant Receives help Total LSNS-18

17.59 20.05 11.14 7.00 7.59 48.77

Gay/ Bisexual Other

15.41 15.05* 7.59 4.54** 4.81*** 38.5**

15.12 17.06 9.12 6.35 5.94 41.29

16.59 14.89 7.56 5.03 5.03 37.04

Total Sample Gay/ Bisexual

Other

16.51 18.94 10.26 6.71 6.87 45.51

16.06 14.96* 7.57 4.81** 4.93*** 37.49**

*p < .05. **p < .01. ***p < .001.

African American, this variable was dichotomized into white people and people of color. Independent sample t tests were conducted by comparing those who identified as white with those who identified as people of color. This analysis produced a consistent pattern in three variables (Table 3). People of color had significantly lower scores on the friends subscale, the confidant item, and the item measuring instrumental social support. The differences found between the white respondents and people of color were significantly more pronounced in those 50 years and older compared with those ages 20 to 39. The older adults of color had significantly lower scores with regard to friends [t(42) = −2.53, p < .05], the availability of a confidant [t(42) = −3.87, p < .001], and instrumental support [t(42) = −2.96, p < .01].The differences in these elements of social networks were significant in both younger and older adults, but the significance was greater when examining only older people (Table 3). Disease and Symptomatology. The final comparison examined the potential impact of disease severity

(HIV compared with AIDS) on social networks. An independent t test was conducted comparing populations and HIV status. The only significant difference was in the 50 and older group, in which those with AIDS had significantly higher scores related to the confidant item than those with HIV [t(42) = −2.04, p < .05]. In no other case did any differences reach statistical significance. Social Isolation. For the practitioner, a major utility in examining social networks may be associated with social isolation. Lubben and Gironda (2003) characterized social isolation as having “extremely limited social support networks” (p. 326). Because of the strong association between social isolation, morbidity, and mortality (House, 2001), it stands to reason that social isolation negatively affects the lives of people living with HIV disease and therefore deserves examination in this study. The LSNS-18 does not specifically identify a clinical cutoff for social isolation. However, the original 10-item version did (Levine, 2000). In that shorter, original version of the LSNS, with a maximum

Table 3: Eighteen-Item Lubben Social Network Scale (LSNS-18) Subscores and Total Score Means by Age Group and Race

Ages 20–39

Scale White

Relative subscore Friend subscore Neighbor subscore Confidant Receives help Total LSNS-18

15.97 19.23 10.19 6.41 6.87 45.39

Age 50 or Older

People of Color White

17.77 13.54* 7.38 4.23* 4.61* 38.69

16.58 17.48 8.68 6.48 6.06 42.74

Total Sample

People of Color White

14.69 11.54* 6.92 3.30*** 3.76** 29.00**

16.27 18.35 9.44 6.45 6.46 44.06

People of Color

16.23 12.54*** 7.15 3.76*** 4.19*** 33.85**

*p < .05. **p < .01. ***p < .001.

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possible score of 50, individuals with scores below 20 were considered to be at risk of social isolation (Lubben, 1988). Using the same percentile rating, in this study individuals with scores below 36 (of 90) were considered socially isolated. Approximately 32 percent of all participants had LSNS-18 scores indicating social isolation. A chi-square statistic was used to compare the two age groups for social isolation. Although 25 percent of those ages 20 to 39 years met the criteria for social isolation, the percentage for those socially isolated in the 50 and older age group increased to 38.6 percent. Although this increase was substantial, it was not statistically significant. A second chi-square was run comparing older adults of color with their white counterparts. In older adults of color, 53.8 percent had LSNS-18 scores indicating social isolation. The difference between older white adults and older adults of color again did not reach statistical significance. When older adults of color were compared with those ages 20 to 39, the difference was significant [χ2(1, N = 57) = 3.86, p < .05]. The pattern seen in this analysis reflects an increasing vulnerability to social isolation when age and race are considered together. Stigma and Social Networks. The final research question sought to examine what relationship, if any, existed between the phenomenon of HIV stigma and social networks. HIV stigma has been defined as prejudice, discounting, discrediting, and discrimination that are directed at people perceived to have HIV or AIDS (Herek et al., 1998). To answer this question, the three subscales, as well as the confidant and instrumental help variables, were placed into a correlation equation along with HIV stigma scores. None of the standard LSNS-18 subscales correlated significantly with HIV stigma; however, all LSNS-18 variables where negatively correlated with stigma. The confidant score was significantly related to stigma (r = −.309, p < .01) and to instrumental assistance (r = −.289, p < .01). DISCUSSION

This study examined the social networks of older and younger adults living with HIV/AIDS to determine the potential role of social networks in mediating HIV stigma and to evaluate the risk of social isolation among the study population. The results reinforce several important facts related to HIV disease and aging, as well as shed additional light on other areas of social interaction. For both

older and younger adults with HIV disease, family and friends play a significant role in the composition of social networks. Neighbors, although part of the network for both groups, served perhaps a different function and to a lesser degree. Adams (1986) noted that neighbors often help when it is convenient and may have more predictable and more narrowly defined roles. The findings of this study suggest that although neighbors may play a role in the social networks of HIV-infected adults of all ages, they play, proportionately, a lesser role than family and friends. The findings of this study support those of numerous studies previously cited, suggesting that older adults with HIV/AIDS are more likely to live alone than their younger counterparts. Gender may play an important role in the development of social networks. In this study, older men were found to have significantly lower scores on several social network measures than their younger male counterparts. These findings are consistent with those of Chesney and colleagues (2003), who found that older men with HIV have less social support than their younger counterparts. Therefore, older men with HIV/AIDS should be evaluated carefully for social isolation. The findings, relative to age and sexual orientation, reinforce earlier knowledge about the social networks of gay, lesbian, bisexual, and transgender individuals. For both age groups, the friends subscale yielded higher scores than family, suggesting more people, more support, or both coming from friends. This finding supports the literature regarding gay, lesbian, bisexual and transgender individuals’ creating families of choice (Butler, 2004; deVries & Blando, 2004) to provide extensive support in time of need. This availability of a broader social network has been seen by some as a social advantage (Butler). The importance of friends, as reflected by higher scores than family on the LSNS-18, is consistent for both older and younger gay and bisexual individuals. Therefore, the acknowledgment and inclusion of family of choice is critical when evaluating and working with sexual minority individuals with HIV/AIDS. The findings of this study relative to race are important to consider.With one exception in which older people of color had higher scores on the relative subscale than their younger counterparts, people of color, and particularly older adults of color, had consistently lower scores on all domains of the


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LSNS-18. Significant differences were found related to friends and the availability of emotional support (a confidant) as well as instrumental support. Although these findings were not a priori conclusions of this research, they support earlier studies. Heckman and colleagues (2000) found older African Americans with HIV to be less likely than their white counterparts to disclose their HIV status to close friends. Brown and Sankar (1998) have suggested that despite historically greater support from family, older African Americans with HIV may face rejection from family, friends, and religious institutions because of the socially stigmatized behaviors associated with HIV transmission. Jimenez (2003), in his study of older men of color, found that having HIV/AIDS was rated very high as a stigmatizing condition. When informal support networks are unavailable, people may turn to formal services for support. It is important to note, however, that Emlet (2004) found that older HIV-infected adults of color were less likely than their white counterparts to have heard of various HIV services available in the community. Furthermore, having not heard of services was significantly associated with decreased use. Considering the disproportionate impact of HIV/AIDS on communities of color, it is critical that social workers and others working in HIV/AIDS consider the potential vulnerability of older populations of color with regard to HIV prevention, education, and service delivery.The findings from this study suggest that gender, heterosexual transmission, and racial background may have an impact on the availability of informal social support. The data also suggest a relationship between social support and stigma.The negative correlation between stigma and emotional and tangible support reinforces previous research on the importance of such support in managing HIV-related stigma.The quantitative studies of Lee and colleagues (2002), Heckman and colleagues (2002), and Emlet (2006) have suggested a parallel relationship between stigma and social support. Similarly, Lichtenstein and associates (2002) have provided qualitative evidence that social support is related to managing stigma. LIMITATIONS

This study has various limitations that must be acknowledged. First, the sample was purposive and nonrandomized. Second, all respondents were clients of an AIDS service organization. These two factors suggest the possibility of sampling bias and that all

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respondents would be connected to some level of support and advocacy through the AIDS service organization. Also, all respondents were from the Pacific Northwest, so generalizations outside of the region cannot be made. To examine changes, as opposed to differences, in social networks over time, a longitudinal design would have been ideal. Restriction of time and funding, however, required a cross-sectional approach. This approach is less able to detect changes over time as opposed to differences between populations. The study does, however, provide a focused comparison of social networks and social isolation among older and younger adults, which was the original purpose of the research. Additional research including a larger, more representative sample from a broader geographic area as well as with increased racial and ethnic diversity may provide further insight into the relationship between social networks and aging among adults living with HIV/AIDS. As life expectancy among people with HIV/AIDS increases, longitudinal studies should be considered. IMPLICATIONS FOR SOCIAL WORK PRACTICE

As the number of adults age 50 years and older living with AIDS continues to increase, the potential for social workers to interact professionally with this population, regardless of practice setting, also increases. At one time, a social worker had to work in a large, urban hospital or an AIDS service organization to see older clients with HIV disease. Recently, Emlet and Poindexter (2004) suggested that both aging and HIV are ubiquitous to social work practice and that social workers must be prepared to provide services to clients in those areas. The findings from this study suggest that age, coupled with race, ethnicity, or gender, can further affect the potential for social isolation. Therefore, social workers can and should respectfully ask older clients if they have questions or concerns about HIV or AIDS, thereby normalizing the issue and giving the client permission to speak about it (Emlet & Poindexter). When working with HIV-infected clients, particularly older individuals, systematic methods should be used for assessing sources of social support.The most abbreviated version of the LSNS (six items) (Lubben & Gironda, 2003) is an example of a short, clinically oriented scale that can be easily administered as part of the standardized assessment


and takes less than five minutes to complete. HIVrelated stigma in all populations infected or affected by HIV should be carefully considered, and any potential negative impact of stigma addressed. At a very practical level, social workers and other health professionals need to be knowledgeable about services funded through mechanisms such as the Older Americans Act and the Ryan White CARE Act to provide referrals to formal services. Formal services may augment or take the place of lacking informal networks. As a beginning, regardless of practice setting, social workers need to personally fight against ageist, homophobic, or HIV-stigmatizing beliefs in themselves, their colleagues, and the general public that could reinforce myths about aging, sexuality, and HIV/AIDS. REFERENCES Adams, R. G. (1986). Secondary friendship networks and psychological well-being among elderly women. Activities, Adaptation and Aging, 8, 59–72. Antonucci, T. C., & Depner, C. E. (1982). Social support and informal helping relationships. In T. A. Wills (Ed.), Basic processes in helping relationships (pp. 233–254). New York: Academic Press. Antonucci, T. C., & Knipscheer, K.C.P.M. (1990). Social network research: Review and perspectives. In K.C.P.M. Knipscheer & T. C. Antonucci (Eds.), Social network research: Substantive issues and methodological questions (pp. 161–173). Amsterdam: Swets & Zeitlinger. Brown, D. R., & Sankar, A. (1998). HIV/AIDS and aging minority populations. Research on Aging, 20, 865–884. Butler, S. S. (2004). Gay, lesbian, bisexual and transgender (GLBT) elders: The challenges and resilience of this marginalized group. Journal of Human Behavior in the Social Environment, 9(4), 25–44. Catz, S. L., Gore-Felton, C., & McClure, J. B. (2002). Psychological distress among minority and low-income women living with HIV. Behavioral Medicine, 28(2), 53–60. Centers for Disease Control and Prevention. (2005). HIV/AIDS Surveillance Report 2004 (Vol. 16). Atlanta: Author. Chesney, M. A., Chambers, D. B., Taylor, J. M., & Johnson, L. M. (2003). Social support, distress and well-being in older men living with HIV infection. Journal of Acquired Immune Deficiency Syndromes, 33(Suppl. 2), S185–S193. Collins, R. L. (1994). Social support provision to HIVinfected gay men. Journal of Applied Social Psychology, 24, 1848–1869. Cowdery, J. E., & Pesa, J. A. (2002). Assessing quality of life in women living with HIV infection. AIDS Care, 14, 235–245. Cox, L. E. (2002). Social support, medication compliance and HIV/AIDS. Social Work in Health Care, 35, 425–460. Crystal, S., Akincigil, A., Sambamoorthi, U., Wenger, N., Fleishman, J. A., Zingmond, D. S., Hays, R. D., Bozzette, S. A., & Shapiro, M. F. (2003). The diverse older HIV-positive population: A national profile of economic circumstances, social support and quality of life. Journal of Acquired Immune Deficiency Syndromes, 33(Suppl. 2), S76–S83.

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Charles A. Emlet, PhD, MSW, is associate professor, Social Work Program, University of Washington,Tacoma, 1900 Commerce Street, Campus Box 358425,Tacoma,WA 98402-3100; e-mail: [email protected]. This study was supported by a grant from the John A. Hartford Foundation and the Gerontological Society of America through the Geriatric Social Work Faculty Scholars Program. Original manuscript received February 3, 2006 Accepted July 26, 2006

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