After the widespread implementation of combination antiretroviral therapy, the life expectancy of people with HIV (PWH) increased markedly to 76 years of age (Marcus et al., 2020). In the United States, more than half of PWH were 50 years old or older in 2018, and the number of older PWH is anticipated to increase (Centers for Disease Control and Prevention, 2021b). As PWH live longer, many are likely to experience comorbidities earlier and more frequently than the general population (Guaraldi et al., 2015; Marcus et al., 2020; Morales et al., 2022; Roomaney et al., 2022). Among several comorbidities, PWH may experience pulmonary diseases, which are a major cause of morbidity and mortality for PWH (Cribbs et al., 2020).

Approximately 10–23% of PWH experience chronic obstructive pulmonary disease (COPD), the third-leading cause of death worldwide (Bigna et al., 2018; Byanova et al., 2021; Global Initiative for Chronic Obstructive Lung Disease, 2021). COPD is an irreversible chronic respiratory disease characterized by consistent respiratory symptoms such as shortness of breath, cough, and sputum production (Global Initiative for Chronic Obstructive Lung Disease, 2021). COPD is caused by prolonged exposure to toxic elements (e.g., smoking and workplace dust) or preceding respiratory diseases (e.g., asthma; Global Initiative for Chronic Obstructive Lung Disease, 2021). The high prevalence of COPD in PWH is related to chronic systemic inflammation, abnormalities in immune function, and chronic innate immune activation related to HIV (Cribbs et al., 2020). Although the high smoking rate is one of the major risk factors contributing to COPD in PWH, HIV infection itself is an independent risk factor for COPD, even after controlling for smoking (Bigna et al., 2018).

Because of these HIV-related risk factors, PWH experience COPD at an earlier age than the general population (mean age 49.7 vs. 65.2 years) and have more frequent COPD exacerbations (Antoniou et al., 2020; Depp et al., 2016; Kayongo et al., 2020), leading to poor health outcomes in PWH (Raju et al., 2020). Furthermore, PWH with airway obstruction, a typical characteristic of COPD, have 3.1 times the risk of death than those without airway obstruction (Triplette et al., 2018). Given the increased likelihood of older PWH experiencing COPD and the subsequent detrimental prognosis, studying the health-related outcomes of this population is imperative.

Depressive symptoms and anxiety are prevalent among PWH, with more than 50% experiencing depressive symptoms and approximately 30% experiencing anxiety, both of which cause worse QoL in older PWH (Brandt et al., 2017; Olson et al., 2019; Rooney et al., 2019). In people with COPD, depressive symptoms and anxiety have a negative impact on QoL and an increased likelihood of readmission to hospital for acute exacerbations of COPD (Jang et al., 2019; Pooler & Beech, 2014). Despite the psychological symptomatology prevalent in HIV and COPD, there is a lack of studies investigating the depressive symptoms and anxiety of older PWH with COPD.

On the other hand, the impact of having COPD on QoL of PWH was examined in the AIDS Linked to the Intravenous Experience study, which is a prospective cohort study of injection drug users. In the AIDS Linked to the Intravenous Experience study, Drummond et al. (2010) examined the impact of smoking and COPD on QoL in people with or at risk of HIV and showed that COPD was associated with worse QoL than smoking. The study highlighted the significance of studying the QoL of PWH with COPD; however, it did not solely focus on older PWH, who may face additional considerations related to their age and health status.

The purpose of this descriptive cross-sectional study was to examine differences in depressive symptoms, anxiety, and QoL between older PWH with and without COPD. In addition, as exploratory aims, this study examined associations among depressive symptoms, anxiety, and QoL based on the diagnosis of COPD and race. Race is a crucial factor for comprehending the population with HIV because Black individuals disproportionally account for 42.1% of PWH in the United States (Centers for Disease Control and Prevention, 2021a). This study reported the findings from a cohort study conducted in an HIV-specialty outpatient clinic located in Alabama, where Black individuals comprise 63.5% of PWH (Black: 26.5% of Alabama's total population; Alabama Department of Public Health, 2019). Alabama is located in the Deep South, which has higher diagnosis and mortality rates of HIV and COPD than the US average for these diseases (Reif et al., 2017). This study may inform further research or intervention development for older PWH with COPD living in the US Deep South.

Methods

This study was a descriptive analysis of data from the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort, which is a part of the Center for AIDS Research Network of Integrated Clinical Systems (CNICS; an National Institutes of Health-funded program R24 AI067039 and P30 AI027767). The CNICS integrates demographic and clinical data, treatment management, and behavioral outcomes of PWH attending CNICS sites to comprehensively understand the interrelationships among these factors. The UAB 1917 Clinic Cohort, established in 1988, is a prospective observational study of PWH who receive primary and subspecialty care. Approval from the UAB Institutional Review Board was obtained (IRB#300009685) for this study.

Sample

Data of individuals diagnosed with HIV for greater than 1 year who attended a primary care provider appointment at the UAB 1917 Clinic from January 2018 to February 2020 were extracted. The period was chosen to include the period before the COVID pandemic to avoid potential confounding effects of the COVID pandemic on characteristics of PWH with and without COPD.

For the study, inclusion criteria were (a) aged 50 years and older; (b) English speaker; and (c) diagnosed with HIV for at least 1 year. The age cutoff was set to 50 years based on previous studies that defined PWH aged 50 years and older as older adults because of low and slow immunological recovery after antiretroviral therapy (ART) and prevalent age-related comorbidities and geriatric syndrome (Blanco et al., 2012; Sánchez-Conde et al., 2019).

Exclusion criteria were those who were cognitively impaired when the data were collected (eligibility of parent study; Kozak et al., 2012). Considering this study is a preliminary descriptive study regarding older PWH with COPD, we did not exclude people with other comorbidities to capture the whole picture of the sample.

Procedure and Instruments

During their clinic visits, participants completed patient-reported outcomes (PROs), an aggregate instrument using standardized questionnaires, through computers. For the purpose of the study, depressive symptoms, anxiety, and QoL questionnaires in the PROs database were included for analyses. Participants complete the PROs every 4–6 months during their clinic visits. For this study, the first assessments of participants who completed PROs from January 2018 to February 2020 were analyzed. Additional demographic and clinical characteristics were collected through electronic medical record.

Electronic medical record data included age, gender (0 = male and 1 = female), race (0 = White and 1 = Black), smoking (0 = never, 1 = previous, and 2 = current), alcohol use (0 = no risk, 1 = low risk, and 2 = at risk), drug use (0 = never, 1 = previous, and 2 = current), Ryan White funding status (i.e., the US federal funding for HIV care for individuals without health insurance or those with limitations in health insurance), numbers of years diagnosed with HIV, combination antiretroviral therapy, nadir CD4, comorbidities, number of prescribed medications, hospitalizations, and visits to the emergency department. For this study, Charlson Comorbidity Index was modified to report a total number of comorbidities (e.g., myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular accident or transient ischemic attacks, dementia, connective tissue disease, peptic ulcer disease, liver disease, diabetes mellitus, hemiplegia, chronic kidney disease, solid tumor, leukemia, lymphoma, and acquired immunodeficiency syndrome) except for COPD (Charlson et al., 1987). Calculating weighted scores according to the severity of comorbidities suggested in the original Charlson Comorbidity Index was not feasible because the data on comorbidities in the 1917 Clinic Cohort had limited information on the severity of conditions. The total number of hospitalizations and visits to the emergency department during the study period was identified. In addition, the numbers of hospitalizations and visits to the emergency department because of respiratory symptoms were identified using key words such as shortness of breath, SOB, short of breath, dyspnea, cough, and sputum.

Patient Health Questionnaire-9

In PROs, depressive symptoms of PWH were measured by Patient Health Questionnaire-9 (PHQ9; Kroenke et al., 2001). The instrument is a 9-item self-administered questionnaire, and each item is scored from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 27; 0–4 (no depressive symptom), 5–9 (mild), 10–14 (moderate), 15–19 (moderately severe), and 20–27 (severe). In a previous study of PWH, PHQ9 showed acceptable internal consistency with Cronbach's α = 0.78 (Monahan et al., 2009). In this study, reliability was Cronbach's α = 0.87.

Patient Health Questionnaire-5 Anxiety

In PROs, anxiety of PWH was measured by Patient Health Questionnaire-5 Anxiety (PHQ5A), which is part of the PHQ (Kroenke et al., 2010; Löwe et al., 2003; Spitzer et al., 2000). The instrument is a 5-item self-administered questionnaire assessing anxiety. Each item is scored 0 (no) or 1 (yes), and the total score ranges from 0 to 5; 0 (no anxiety), 1–4 (anxiety symptoms), and 5 (panic syndrome). In a previous study of PWH, internal consistency was acceptable (Cronbach's α = 0.65; Reif et al., 2004). In this study, PHQ5A showed internal consistency with Cronbach's α = 0.67.

EuroQol-5 Dimension

In PROs, QoL of PWH was measured using EuroQoL-5 Dimension (EQ-5D), which consists of five dimensions (i.e., mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) plus EQ-5D visual analog scale (EQ VAS; Rabin & de Charro, 2001). The five dimensions have three levels; 1 (no problem), 2 (some problems), and 3 (extreme problems). The EQ VAS records general health status on a vertical VAS from 0 (the worst health you can imagine) to 100 (the best health you can imagine). Scores are reported separately by each dimension. In a previous study of PWH, EQ-5D showed acceptable internal consistency with Cronbach's α = 0.72 (Ahmed et al., 2021). In this study, internal consistency among five dimensions was Cronbach's α = 0.71.

Statistical Analysis

We excluded one participant who identified as transgender (0.1%) and 10 PWH of races other than White and Black (1.43%) because of their small sample size, which makes it challenging to provide accurate interpretations of results. Descriptive analyses (mean values and SDs; frequencies and percentages) were used to describe the characteristics of participants (Table 1). The characteristics of PWH with COPD were compared with PWH without COPD using independent-sample t-tests for continuous variables and Pearson chi-square test for categorical variables (Table 2). Multiple regression analysis was used to identify the impact of COPD on depressive symptoms, anxiety, and QoL, while controlling for age, gender, and number of comorbidities. Pearson correlation coefficient analyses were used to examine associations among variables (Tables 3–5). Analyses were conducted with a significance level of p = .05. All analyses were conducted using SPSS.

Table 1. - Demographic and Clinical Characteristics of PWH With and Without COPD (N = 690) PWH With COPD (n = 102) PWH Without COPD (n = 588) p Value Effect Size M (SD) or n (%) Demographic  Age 59.10 (5.38) 57.78 (5.75) .032 0.231  Gender .829 0.008   Male 76 (74.5%) 444 (75.5%)   Female 26 (25.5%) 144 (24.5%)  Race .878 0.006   Black 56 (54.9%) 318 (54.1%)   White 46 (45.1%) 270 (45.9%)  Smoking (Tobacco) <.001 0.296   Current 54 (54.0%) 131 (22.6%)   Previous 33 (33.0%) 152 (26.2%)   Never 13 (13.0%) 297 (51.2%)  Alcohol use .103 0.082   At risk 20 (19.8%) 110 (19.2%)   Low risk 26 (25.7%) 207 (36.2%)   No risk 55 (54.5%) 255 (44.6%)  Drug use (current/previous/never)   Cocaine/crack 6 (6.3%)/40 (42.1%)/49 (51.6%) 26 (4.8%)/137 (25.2%)/380 (70.0%) .002 0.141   Methamphetamine 2 (2.4%)/12 (14.5%)/69 (83.1%) 6 (1.2%)/63 (12.3%)/442 (86.5%) .560 0.044   Cannabis 31 (32.6%)/26 (27.4%)/38 (40.0%) 139 (25.3%)/140 (25.5%)/270 (49.2%) .204 0.070   Inhalants 1 (1.2%)/16 (18.6%)/69 (80.2%) 21 (4.0%)/91 (17.4%)/412 (78.6%) .418 0.054   Intravenous drug 0 (0%)/12 (24.5%)/37 (75.5%) 0 (0%)/23 (11.6%)/175 (88.4%) .021 0.147  Ryan Whitea 96 (94.1%) 469 (80.7%) <.001 0.126 Clinical  Years diagnosed with HIV 18.18 (8.52) 17.30 (8.43) .333 0.104  On ART (Y) 97 (95.1%) 573 (97.4%) .191 0.050  Nadir CD4 230.75 (224.82) 243.80 (225.94) .590 −0.058  Comorbiditiesb 2.00 (1.48) 1.39 (1.22) <.001 0.487  No. of prescribed medications 15.36 (7.24) 11.68 (6.38) <.001 0.573  Hospitalization data   Total 0.66 (1.43) 0.27 (1.04) .010 0.349   Because of respiratory symptom 0.02 (0.14) 0.01 (.09) .439 0.111  ED visits   Total 1.46 (2.29) 0.66 (1.92) .001 0.406   Because of respiratory symptom 0.15 (0.41) 0.05 (.29) .022 0.315

Note. PWH = people with HIV; COPD = chronic obstructive pulmonary disease; ART = antiretroviral therapy; ED = emergency department.

aRyan White: The US federal funding for HIV care for individuals without health insurance or those with limitations in health insurance.

bModified Charlson Comorbidity Index (CCI): myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular accident or transient ischemic attack, dementia, connective tissue disease, peptic ulcer disease, liver disease, diabetes mellitus, hemiplegia, moderate-to-severe chronic kidney disease, solid tumor, leukemia, lymphoma, and AID.

Table 2. - Health Outcomes of PWH With and Without COPD (N = 690) PWH With COPD (n = 102) PWH Without COPD (n = 588) p Value Effect Size PHQ9 (Depression) .004 0.151  No depressive symptom 53 (52.0%) 410 (70.3%)  Mild 32 (31.4%) 115 (19.7%)  Moderate 12 (11.8%) 31 (5.3%)  Moderately severe 3 (2.9%) 17 (2.9%)  Severe 2 (2.0%) 10 (1.7%) PHQ5A (Anxiety) .776 0.027  No anxiety 83 (83.0%) 488 (84.1%)  Anxiety symptom 8 (8.0%) 51 (8.8%)  Panic syndrome 9 (9.0%) 41 (7.1%) EQ-5D (quality of life)  Mobility 1.44 (.52) 1.28 (.46) .003 0.352  Self-care 1.16 (.37) 1.07 (.29) .026 0.285  Usual activities 1.40 (.51) 1.21 (.44) <001 0.429  Pain/discomfort 1.93 (.65) 1.57 (.65) <.001 0.561  Anxiety/depression 1.33 (.55) 1.27 (.50) .254 0.131  General health status 73.79 (21.70) 76.78 (23.73) .236 −0.127

Note. COPD = chronic obstructive pulmonary disease; EQ-5D = EuroQol-5 Dimension; PHQ5A = Patient Health Questionnaire-5 Anxiety; PHQ9 = Patient Health Questionnaire-9; PWH = people with HIV. For EQ-5D, mobility, self-care, usual activities, pain/discomfort, and anxiety/depression have three levels: 1 (no problem), 2 (some problem), and 3 (extreme problems). General health status ranges from 0 (the worst health you can imagine) to 100 (the best health you can imagine).

Table 3. - Correlation Matrix for PWH (N = 690)

Note. Categorical variables were coded as follows: COPD (no = 0 and yes = 1), Gender (male = 0 and female = 1), race (White = 0 and Black = 1), Smoking (never = 0, previous = 1, and current = 2), Alcohol (no risk = 0, low risk = 1, and at risk = 2), PHQ9 (no depressive symptoms = 0, mild = 1, moderate = 2, moderately severe = 3, and severe = 4), and PHQ5A (no anxiety = 0, anxiety symptom = 1, and panic syndrome = 2). COPD = chronic obstructive pulmonary disease; EQ-5D = EuroQol-5 Dimension; ED = emergency department; PHQ9 = Patient Health Questionnaire-9; PHQ5A = Patient Health Questionnaire-5 Anxiety; PWH = people with HIV.

*Correlation is significant at the 0.05 level (2-tailed).

*Correlation is significant at the 0.01 level (2-tailed).

Table 4. - Correlation Matrix for PWH With COPD (Gray/Top Half) and Without COPD (White/Bottom Half)

Note. Categorical variables were coded as follows: COPD (no = 0 and yes = 1), Gender (male = 0 and female = 1), Race (White = 0 and Black = 1), Smoking (never = 0, previous = 1, and current = 2), Alcohol (no risk = 0, low risk = 1, and at risk = 2), PHQ9 (no depressive symptoms = 0, mild = 1, moderate = 2, moderately severe = 3, and severe = 4), and PHQ5A (no anxiety = 0, anxiety symptom = 1, and panic syndrome = 2). COPD = chronic obstructive pulmonary disease; EQ-5D = EuroQol-5 Dimension; ED = emergency department; PHQ9 = Patient Health Questionnaire-9; PHQ5A = Patient Health Questionnaire-5 Anxiety; PWH = people with HIV.

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

Table 5. - Correlation Matrix for PWH With and Without COPD Based on Race (Black: Top Half/White: Bottom Half)

Note. Categorical variables were coded as follows: COPD (no = 0 and yes = 1), Gender (male = 0 and female = 1), Race (White = 0 and Black = 1), Smoking (never = 0, previous = 1, and current = 2), Alcohol (no risk = 0, low risk = 1, and at risk = 2), PHQ9 (no depressive symptoms = 0, mild = 1, moderate = 2, moderately severe = 3, and severe = 4), and PHQ5A (no anxiety = 0, anxiety symptom = 1, and panic syndrome = 2). COPD = chronic obstructive pulmonary disease; EQ-5D = EuroQol-5 Dimension; ER = emergency department visit; PHQ9 = Patient Health Questionnaire-9; PHQ5A = Patient Health Questionnaire-5 Anxiety; PWH = people with HIV.

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

Results Demographic and Clinical Characteristics of People With HIV With and Without Chronic Obstructive Pulmonary Disease

Of 690 older PWH, 102 (14.8%) individuals were diagnosed with COPD. Compared with PWH without COPD, PWH with COPD were older (59.10 years old vs. 57.78 years old, p = .032, d = 0.231) and had a greater history of smoking (p < .001, d = 0.296; Table 1). In addition, PWH with COPD had a higher number of comorbidities (2.00 vs. 1.39, p < .001, d = 0.487), prescribed medications (15.36 vs. 11.68, p < .001, d = 0.573), hospitalizations (0.66 vs. 0.27, p = .010, d = 0.349), and visits to the emergency department (1.46 vs. 66, p = .001, d = 0.406) compared with those without COPD. PWH with COPD visited an emergency department because of respiratory symptoms more often than those without COPD (0.15 vs. 0.05, p = .022, d = 0.315), but there was no difference in the number of hospitalizations because of respiratory symptoms between PWH with and without COPD.

Group Difference in Psychological Symptomatology and Quality of Life

As seen in Table 2, depressive symptoms were worse in older PWH with COPD than those without COPD (p = .004, Cramer's V = 0.151). On the other hand, anxiety levels showed no difference between PWH with and without COPD. Among components of EQ-5D, older PWH with COPD showed worse mobility (p = .003, d = 0.352), worse self-care (p = .026, d = 0.285), poorer usual activities (p < .001, d = 0.429), and greater pain/discomfort (p < .001, d = 0.561) than those without COPD, but there was no difference in general health state.

When controlling for age, gender, and the number of comorbidities, it was found that diagnosis of COPD significantly predicted worse depressive symptoms (p = .016), poorer mobility (p = .012), poorer self-care (p = .019), worse usual activities (p < .001), and greater pain/discomfort (p < .001), but not anxiety (p = .397) and general health state (p = .300).

Associations Between Psychological Symptomatology and Quality of Life

Table 3 describes associations between psychological symptomatology and QoL for the entire sample, including both older PWH with and without COPD. Worse depression symptoms were moderately correlated with worse anxiety (p < .001, r = 0.489), poorer mobility (p < .001, r = 0.312), poorer usual activities (p < .001, r = 0.434), greater pain or discomfort (p < .001, r = 0.324), and poorer general health (p < .001, r = −0.331). Depression and self-care were negatively, weakly correlated (p < .001, r = 0.201). Worse anxiety showed a weak correlation with worse mobility (p < .001, r = 0.225), worse self-care (p < .001, r = 0.155), poorer usual activities (p < .001, r = 0.298), greater pain or discomfort (p < .001, r = 0.212), and poorer general health (p < .001, r = −0.228).

Table 4 shows associations between psychological symptomatology and QoL depending on the diagnosis of COPD in PWH. For older PWH with COPD, worse depressive symptoms had a moderate positive correlation with worse anxiety (p < .001, r = 0.330), poorer mobility (p < .001, r = 0.346), poorer usual activities (p < .001, r = 0.368), greater pain or discomfort (p < .001, r = 0.329), and poorer general health (p < .001, r = −0.344). For older PWH without COPD, worse depression was strongly associated with worse anxiety (p < .001, r = 0.522) and moderately associated with poorer usual activities (p < .001, r = 0.438), greater pain or discomfort (p < .001, r = 0.308), and poorer general health (p < .001, r = −0.326). Anxiety was only weakly correlated with greater pain or discomfort for PWH with COPD (p = .027, r = 0.222), whereas greater anxiety exhibited a weak-to-moderate correlation with all components of EQ-5D for PWH without COPD, poorer mobility (p < .001, r = 0.255), poorer self-care (p < .001, r = 0.160), poorer usual activities (p < .001, r = 0.324), greater pain or discomfort (p < .001, r = 0.211), and poorer general health (p < .001, r = −0.238).

Table 5 describes associations between psychological symptomatology and QoL based on race. For Black individuals, diagnosis of COPD was weakly correlated with worse depressive symptoms (p = .042, r = 0.106), poorer self-care (p = .001, r = 0.168), poorer usual activities (p = .007, r = 0.140), and greater pain or discomfort (p < .001, r = 0.172). For White individuals, diagnosis of COPD was weakly associated with worse mobility (p = .002, r = 0.175), poorer usual activities (p = .003, r = 0.164), greater pain or discomfort (p < .001, r = 0.229), and poorer general health (p = .019, r = −0.132).

Discussion

This study compared differences in psychological symptomatology and QoL between older PWH with and without COPD; the exploratory aim was to identify associations between psychological symptomatology and QoL based on their diagnosis of COPD and race. Differences were observed in depressive symptoms and components of QoL between older PWH with and without COPD. This result can be explained by decreased lung function and respiratory symptoms that older PWH with COPD experience. Raju et al. (2020) found that PWH with poor lung function showed worse QoL than people without HIV. According to Won et al. (2020), chronic cough is an independent factor that affects components of QoL, including mobility, self-care, usual activities, pain or discomfort, anxiety or depression, and general health status for the general population. In that study, people older than 65 years experienced even worse QoL because of chronic cough (Won et al., 2020). In addition, dyspnea frequency was related to depressive symptoms in people with COPD (Schuler et al., 2018). Also, other factors common for PWH and people with COPD, such as fatigue and stigma, may be involved in depressive symptoms and QoL of older PWH with COPD. Therefore, depressive symptomatology, each component of QoL, and related factors need to be identified more specifically to develop effective interventions and improve the mental health and QoL of older PWH with COPD.

Although anxiety is prevalent for people with COPD in the literature (Fuller-Thomson & Lacombe-Duncan, 2016), in this study, there was no significant difference in anxiety levels between older PWH with and without COPD. In addition, only pain or discomfort was weakly correlated with the anxiety of older PWH with COPD, whereas all components of EQ-5D had weak-to-moderate correlations with the anxiety of older PWH without COPD. There may be protective factors that relieve the anxiety of older PWH with COPD, such as resilience or spirituality. Another potential explanation may be that the intense anxiety surrounding HIV eclipses anxiety related to COPD, as supported by a study showing that the stigma associated with HIV overshadowed that of COPD (Byun et al., 2023). As such, questions remain regarding the impact of COPD on anxiety and whether other variables better explain the associations. Nonetheless, the importance of managing anxiety remains significant because depressive symptoms and anxiety showed a significant association for older PWH in this study.

Associations between psychological symptomatology and QoL were also examined based on race. The results indicated that among Black individuals, COPD was associated with depressive symptoms, self-care, usual activities, and pain or discomfort, whereas for White individuals, COPD was significantly associated with mobility, usual activities, and pain or discomfort. These findings suggest that the health outcomes of older PWH with COPD may vary based on their race, highlighting the need for tailored interventions that address different components of health outcomes.

The presence of COPD in older PWH was associated with a higher number of comorbidities and prescribed medications, suggesting that they face a range of health challenges and need to manage their conditions accordingly, albeit self-care was worse in older PWH with COPD than those without COPD. This posits serious concerns about the prognosis of older PWH with COPD because worse self-care is associated with more frequent acute exacerbations of COPD (Zwerink et al., 2014). More frequent hospitalizations, visits to the emergency department, and visits to the emergency department because of respiratory symptoms in older PWH with COPD were observed in this study. Our study findings align with a previous study by Depp et al. (2016), which showed that PWH are at higher risk of more frequent and severe exacerbations of COPD, suggesting a poorer prognosis than those without HIV. Yet, no difference in hospitalizations suggests the possibility that some of our participants may have been underdiagnosed with COPD or could have had other cardiovascular and pulmonary diseases that cause respiratory symptoms. Drummond et al. (2011) and Gingo et al. (2018) reported the underdiagnosis of COPD in PWH and suggested integrating lung screening into HIV care to facilitate early detection and treatment.

Strengths and Limitations

There are several strengths of this study. First, this study was the first study exploring psychological symptomatology and QoL of older PWH with COPD. The previous study regarding the health outcome of PWH with COPD focused mainly on QoL and did not target older adults (Drummond et al., 2010; Kayongo et al., 2020). In addition, most recent studies regarding this population focus on the pathology, prevalence, and screening of COPD in PWH (Bigna et al., 2018; Depp et al., 2016; Gingo et al., 2018; Quiros-Roldan et al., 2019). Second, this study was conducted in the Deep South, where the prevalence of HIV and COPD is higher than the average in the United States (AIDSVu, 2019; Sullivan et al., 2018). This difference can be attributed to the populations' lower socioeconomic status and disparities in access to health care (AIDSVu, 2019; Sullivan et al., 2018). The current study can provide evidence for future works to improve the aging of this vulnerable population living in the Deep South.

The study was limited by using clinic data. First, the study has limited generalizability. The study participants included individuals who visited a tertiary clinic in an urban area, raising concerns about potential referral bias and exclusion of individuals residing in rural areas or lacking transportation to access comparable health care facilities. Second, COPD-related measurements are lacking because the UAB 1917 Clinic Cohort mainly focuses on HIV. Our study included instruments applicable and validated in both HIV and COPD (e.g., PHQ9, PHQ5A, and EQ-5D). Third, there was a significant amount of missing data on drug use. Smoking tobacco, cocaine, cannabis, or inhalant usage may negatively affect the lung health of PWH, but we could not conduct further analyses because of a large number of missing data. Fourth, although transgender individuals constitute 2% of diagnoses of HIV in the United States (Centers for Disease Control and Prevention, 2022), our data set included only one transgender participant (0.1%), rendering it unrepresentative. The decision to exclude this individual was guided by the concern that their inclusion alongside nontransgender participants might potentially compromise the specificity of data contributed by a transgen