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Ageing and HIV/AIDS (Aging/HIV Clinic in London): A dedicated clinical service for HIV-infected individuals over 50 years of age
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Reported by Jules Levin
Ms Breda Ward, Dr Amelia Hughes, Dr David Asboe, Dr Simon Barton, Prof Brian Gazzard, Ms Laura Baber, Dr Anton Pozniak, Dr Marta Boffito(runs the clinic)
Chelsea & Westminster Hospital NHS Foundation Trust, London, United Kingdom
AUTHOR CONCLUSIONS
Asymptomatic patients over 50years of age and under long-term follow up were diagnosed with new pathologies, in particular malignancies, only discovered because of targeted screening.
A review of all medication, and understanding of drug-drug interactions, is essential in the management of an ageing population.
This clinic has served to improve GP liaison and patients have reacted positively to the clinic, particularly as many do not access their GP.
Sexual health assessment needs improvement within the clinic.
BACKGROUND
The HIV-infected population is ageing, partly due to availability and efficacy of cART, but also the increase in new HIV diagnoses in older patients. Furthermore, HIV-associated chronic inflammation and pharmacological factors may accelerate ageing. HIV care providers should be prepared to prevent and manage complex co-morbidities and poly-pharmacy in older HIV-infected patients.
At the HIV/GUM directorate at Chelsea and Westminster hospital, we set up a multi-disciplinary service in January 2009 aimed at managing HIV-infected individuals over the age of 50 years. We here present an evaluation of the service following one year of activity.
Methods
A weekly clinic was implemented, dedicated to all patients aged 50 years or above; patients were referred by their regular HIV out-patient clinicians. The inter-disciplinary team consists of a consultant, specialist registrar and nurse practitioner, and all have their own appointment slots. In addition the clinic is supported by a specialist pharmacist and all patients are discussed in a pre-clinic meeting.
Alongside review of routine clinic bloods, the following additional tests and assessments are offered to patients attending the clinic:
· Extensive review of all medications (including over-the-counter, GP prescriptions, herbal and recreational drugs) and risk for drug interactions
· Additional blood tests including PSA, testosterone, vitamin D, therapeutic drug monitoring (tenofovir, NNRTI, PI, raltegravir and maraviroc), iron studies, fasting glucose, B12 and folate
· Urine studies, specifically protein: creatinine and albumin:creatinine ratios
· Bone mineral density (BMD) scan
· Chest X-ray
· CT Coronary artery calcification score (CACS)
· Early neurocognitive assessment using the International HIV Dementia Scale (IHDS)
· Adherence self-assessment questionnaire
· Pychosocial assessment
· Sexual health evaluation
· Recommendation for routine mammography and smear testing
RESULTS
· A potentially significant drug-drug interaction was observed in 6% (4/69); 3 were prescribed lipid-lowering agents by their GP and 1 was prescribed diltiazem with ritonavir
· HDL:cholesterol ratio was raised in 27% (19/69) ; 45% (31/69) were already on a lipid-lowering agent
· Diabetes mellitus had previously been diagnosed in 7% (5/69); 16% (10/64) required an oral glucose tolerance test (if fasting glucose >6) and referral to GP/endocrinology
· 17% (12/69) had known hypertension and all were on anti-hypertensive agents
· 8% (6/69) had a PSA >ULN: 4% (3/69) had a new diagnosis of prostate cancer made within the ageing clinic
· 1 female patient had missed an invitation for mammography and was subsequently diagnosed with breast cancer after she was advised in the ageing clinic to seek screening
· 17% (12/69) had a high CACS (>90th centile for age and sex) and were referred to cardiology for further investigation (See poster p37)
· 14% (13/54) had osteopenia; 11% (6/54) had osteoporosis and were referred to rheumatology (See poster p39)
· 10% (7/69) were referred to the psychologists for neuropsychometric testing; 1 patient was subsequently referred for an MRI brain scan which showed "non-specific findings".
· 34% (23/69) completed an adherence self-assessment; 70% (16/23) missed no doses of medication in the past 1 month
· 24% (17/69) had a documented STI screen in the past year; 29% of those (5/17) had a diagnosed STI
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