Unique Health Care Challenges for Older Adults with HIV
Dr. Meredith Greene, fellow in the Division of Geriatrics at University of California, San Francisco, has spent her career working out how to integrate HIV services and geriatric care. “Traditionally, those areas haven’t overlapped a lot,” she explains—yet as individuals with HIV live longer with increasingly more effective and tolerable HIV therapies, she recognizes the importance of tailoring medical care services for older HIV-positive adults to their unique medical needs.
Individuals with HIV may be at a greater risk of developing age-related health conditions such as cardiovascular (heart) disease, chronic pulmonary (lung) disease, osteoporosis (bone density loss), and cognitive impairment (changes in memory and thinking) than similarly aged peers without HIV.
HIV disease or its treatment may actually contribute to these conditions, explains Greene. She points to recent findings from the Veterans Aging Cohort Study, which demonstrated that individuals living with HIV were 50% more likely to experience heart attacks than similarly aged veterans who did not have HIV, even after adjusting for traditional risk factors such as smoking, substance use, and diabetes.
This link between HIV and other co-occurring disorders makes HIV more difficult to manage and treat. According to Greene, the difficulty in caring for adults over age 50 living with HIV oftentimes stems from a syndrome created by multiple, interacting chronic health conditions on top of HIV, called “multimorbidity.”
Treatment regimens in the presence of multimorbidity may quickly become daunting, as each chronic condition likely requires its own set of prescriptions and instructions. Having to manage and use a complex set of many medications, termed “polypharmacy,” becomes worrisome as drug-drug interactions and adverse drug reactions are more likely. And with each additional health condition, drug-disease interactions must also be considered. “Kidney or liver disease might make certain drugs less of an option for someone,” Greene explains. “For example, if someone has kidney problems, they might not be able to take tenofovir [a widely prescribed HIV drug that can impair kidney function] or have to take a lower dose.”
Oftentimes, multiple chronic conditions in an aging individual create health effects that are more detrimental than would otherwise be expected, making it even more critical for HIV care providers to take into consideration all of their patients’ clinical needs in addition to HIV concerns.
Greene refers to this philosophy of medical care as a “whole-person approach,” where providers coordinate care for patients across domains and disciplines. This approach forms the basis of an extensive project undertaken by Greene and other colleagues at UCSF and the San Francisco General Hospital, called the Patient Centered Medical Home (PCMH). This model of care aims to provide coordinated, high-quality health services and care for older people living with HIV.
For the first part of the project, the PCMH team outlined the types of questions and assessments most relevant for older adults living with HIV. For instance, because older adults living with HIV are at an increased risk for bone thinning and bone loss, the PCMH model of care includes an assessment of falls (which oftentimes cause bone fractures in patients with bone density loss). Other assessments include screenings for depression, anxiety, and post-traumatic stress disorder; questions about social support and loneliness; and memory exams.
Greene did stress the importance of considering “function” first and foremost. How well a person is able to complete activities of daily living—like managing medications, getting dressed, or going shopping—is key as providers assess how well a patient is doing overall.
“Someone might have HIV, heart disease, and kidney disease but still be able to go out and play tennis every day. And then someone who’s the same age and who has the exact same conditions might be having a lot of trouble with activities of daily living and might be in a nursing home. One of the fundamental geriatric principles is that everything comes back to functional status,” explains Greene.
Which again highlights the importance for providers to be able to assess their patients’ health and wellness as a whole—and evaluate the treatment of HIV in this context. This requires a multidisciplinary approach that coordinates the efforts of a number of health care staff. “Because we’re trying to make it interdisciplinary, we’re really trying to approach different people to get that ‘whole person’ care. You have to think of all the different psychosocial issues and health issues. It takes a team to think through and bring every discipline’s perspective to really benefit the patient,” notes Greene.
“That’s something that the San Francisco AIDS Foundation has been doing with the 50-Plus Network: bringing together some of the local agencies that have had a traditional focus on aging or a traditional HIV focus, so we can strategize how these different agencies can be working together, and how people can be linked to services that they need.”
The PCMH project, which has been ongoing since 2011, is now focused on evaluating participants’ experience, to ensure participants are satisfied with the services they receive as part of this novel model of care. “PCMH is called ‘patient centered’ for a reason. We want it to be something that works for patients,” says Greene. A final step will also be to fully integrate the services, assessments, and elements of the PCMH project into the individual clinics so they can be successfully continued even after funding for the project ends.
For additional information for providers working with aging HIV-positive individuals, Greene recommends the HIV-Age website, where you can download clinical recommendations for treating older adults with HIV.