Only a minority of centres have specialist clinics for management of co-morbidities
Two-thirds of HIV clinics in the UK do not think there is a current need for specialist care services targeted at older adults, investigators report in HIV Medicine. “This is important as, although there is no current need because of a lack of a significant proportion of older adults within certain services, there is a clear trajectory towards cohort ageing within the UK,” write the authors. “We would anticipate clinic populations of older adults to grow in time, which may alter this perception of need.”
Improvements in treatment and care mean that most HIV-positive people in the UK now have an excellent prognosis and can expect to survive well into old age. There are also significant numbers of new HIV infections and diagnoses among older individuals. Close to 50% of all people accessing HIV care in the UK are now aged 45 years or older.
HIV infection is associated with an increased prevalence of conditions normally associated with ageing and also some geriatric conditions, such as frailty. HIV is an unusually fast-paced field of medicine and service delivery models have evolved constantly over the past 30 years. Investigators wanted to see if UK clinics were developing services for older patients and what form these services take.
A web-based questionnaire was sent to all 182 clinics providing HIV care in the UK. The questions covered three broad areas: current provision of services for older patients; perceived need for such services; and need for formal guidelines from the British HIV Association (BHIVA) on monitoring and treatment of older adults.
A total of 102 (56%) clinics from across the UK responded. The median clinic population size was 590 patients.
Five of the clinics already had a clinician with a specialist interest in HIV and ageing and two had dedicated ageing services. Both these centres served large patient populations. One centre offered a monthly clinic jointly run by HIV and geriatric specialist physicians. Referral was on the basis of need or age. The second centre ran a weekly clinic operated by an HIV doctor and an HIV clinical nurse specialist with an interest in ageing. This clinic was linked to an interdisciplinary team and offered comprehensive geriatric assessment together with BHIVA-recommended screening and HIV therapy.
Only 23% of centres reported a need for specialist ageing services; these were in development at three clinics. Two-thirds of HIV treatment centres did not believe there was a need for ageing services and the most commonly cited reason (59%) was an insufficient number of older patients. Some centres saw no need to duplicate the high-quality care for conditions related to ageing provided by general practitioners in their areas, while others said that management of ageing should form a routine part of HIV care and did not require specialised service provision.
Where there were no specialist services, 53% of centres reported that they would refer older patients with complex needs to a specialist in geriatric care and 70% said they would refer on to a GP.
Half of the centres reported using the Sheffield University online FRAX tool to calculate patients’ ten-year risk of osteoporosis and hip fracture. However, only 23% routinely enquired about falls. Approximately a third of clinics offered DXA scans to female patients aged over 65 and male patients aged 70 and above, as per BHIVA guidelines.
Cognitive screening was performed using a wide variety of tools.
The majority of centres (68%) said they would welcome BHIVA guidance on the monitoring of elderly patients. Respondents said these should cover communication across specialities and broader information on conditions including non-AIDS cancers, falls, bone density, depression and cardiovascular risk. A large minority (41%) thought there was a need for detailed guidance on the use of HIV therapy in older patients.
“HIV services…have been innovative in adapting to the changing needs of people living with HIV, making good use of specialist joint-clinic models to provide optimal services in certain disease areas,” comment the researchers. “There is no reason why such a model would not work for ageing.”
A separate web-based survey enquired about the management of co-morbidities in older HIV-positive patients. Of the 44 centres that participated, 27% provided one or more service. The most common was a specialist clinic for the management of a non-infectious co-morbidity, most frequently renal, gastroenterology, oncology, neurology and dermatology clinics. Usually, this clinic was a joint service offered by an HIV clinician and a non-HIV specialist.
Dedicated services for older HIV-positive adults were provided at five (11%) centres. Eligibility was based on age (50 years and above) or the presence of a co-morbidity.
Most centres (82%) provided care co-ordination and case management for patients with complex co-morbidities was offered at a quarter of centres.
“Given the increasing burden of comorbidities in this population, developing services to meet the needs of an ageing HIV-infected population is a priority,” conclude the investigators.
By Michael Carter
Cresswell FV et al. Specialist care of older adults with HIV infection in the United Kingdom: a service evaluation. HIV Medicine, online edition. DOI: 10.111/hiv.12481 (2017).
Youssef E et al. The management of comorbidities in older people living with HIV in England: a cross sectional survey. HIV Medicine, online edition. DOI: 10.111/hiv.12484 (2017).