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Evaluation of a Clinic Dedicated to People Aging with HIV at Chelsea and Westminster Hospital: Results of a 10-Year Experience
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13 Aug 2021
"....implementation of clinical care pathways and new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and geriatric) to improve prevention, diagnosis, and management of major comorbidities in people aging with HIV..."
A demographic shift in PLWH is already visible,5,6 and HIV services must be designed to reflect the changing needs of an aging population living with HIV and overcome a fragmentation of HIV care delivery.44,45 In practice, the prevalence of noninfectious comorbidities is increasing as this population ages leading to frequent referrals to multiple specialist services, adding an economic burden and risking a fragmented care. To deliver an integrated patient care, a multidisciplinary clinic for PLWH older than 50 years was implemented in January 2009.10 The results of a service evaluation after 10 years of experience of this clinic indicate a high prevalence of noninfectious comorbidities that largely concurs with similar studies on this topic.2,3,7
Pathways for the assessment and management of major comorbidities in PLWH were revised according to these data and led to the implementation of the following: (1) a dedicated "aging PLWH" clinical pathway to be introduced into the routine clinical practice in all HIV outpatient services under the remit of CWH; and (2) new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and care of the elderly clinics) to deliver specialized but integrated care to patients in a timely manner. These are multidisciplinary clinics run by an HIV physician in conjunction with specialists in different areas of care delivery using a one-stop clinic approach. The aim is to provide integrated medical advice and joint team decisions in one single patient visit, decreasing delays in treatment initiation and reducing the number of hospital visits.
A high prevalence of traditional CVD risk factors such as dyslipidemia (50.1%), hypertension (21.5%), current smoking (34.4%), obesity (11.9%), and diabetes (5.8%) was observed in our cohort. This underscores the importance of primary prevention strategies to aggressively control modifiable risk factors in PLWH. To face the increased needs of this population, we implemented a specialist cardiology/HIV joint clinic as a new clinical service to deliver specialized care to PLWH with established CVD or high CVD risk in a timely manner.
Abstract
Successful management of HIV infection as a chronic condition has resulted in a demographic shift where the proportion of people living with HIV (PLWH) older than 50 years is steadily increasing. A dedicated clinic to PLWH older than 50 years was established at Chelsea and Westminster Hospital in January 2009 and then extended to HIV services across the directorate. We report the results of a service evaluation reviewing 10 years of activities of this clinic between January 2009 and 2019. We aimed to estimate the prevalence of major noninfectious comorbidities, polypharmacy (≥5 medications), and multimorbidity (≥2 non-HIV-related comorbidities) and describe algorithms devised for use in HIV outpatient clinics across the directorate.
A cohort of 744 PLWH older than 50 years attending this service were analyzed (93% male; mean age of 56 ± 5.5 years; 84% white ethnicity); 97.7% were on antiretroviral treatment and 95.9% had undetectable HIV-RNA at the time of evaluation. The most common comorbidities diagnosed were dyslipidemia (50.1%), hypertension (21.5%), mental health disorders (depression and/or anxiety disorders, 15.7%), osteoporosis (12.2%), obesity (11.9%), chronic kidney disease (7.5%), and diabetes (5.8%).
Low vitamin D levels were found in 62% of patients [43% with vitamin D deficiency (<40 mmol/liter) and 57% with vitamin D insufficiency (40-70 mmol/liter)].
The overall prevalence of polypharmacy and multimorbidity was 46.6% and 69.3%, respectively. This study showed significant rates of non-HIV-related comorbidities and polypharmacy in PLWH older than 50 years, leading on to the
implementation of clinical care pathways and new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and geriatric) to improve prevention, diagnosis, and management of major comorbidities in people aging with HIV.
Background
Life expectancy for people living with HIV (PLWH) has improved substantially after the introduction of combined antiretroviral treatment.1 Despite this, increased longevity is inevitably associated with a rising prevalence of age-related comorbidities in PLWH, including cardiovascular disease (CVD), diabetes mellitus, osteoporosis, and neurocognitive impairment.2,3
In the United Kingdom, the proportion of people newly diagnosed with HIV older than 50 years increased from 13% in 2009 to 21% in 2018.4,5 As a consequence of this demographic shift,6 the burden of age-related comorbidities in PLWH is expected to increase overtime, raising the susceptibility to polypharmacy and potential drug/drug interactions (DDIs).7 Furthermore, alterations in drug metabolism with advancing age may lead to increased drug exposure and escalate the risk of adverse side effects.7,8 This underscores the need for a careful review of comedications to identify potential DDIs, particularly between combined antiretroviral treatment (cART) and other prescribed drugs, and prevent the risk of drug toxicity in aging PLWH.8,9
To respond to the changing needs of a population aging with HIV, a specialist HIV service was established for patients older than 50 years at the Chelsea and Westminster Hospital NHS Foundation Trust (CWH) in January 2009.10 This service was initially based at CWH and eventually extended to all sites across the HIV directorate (CWH, 56 Dean Street, 10 Hammersmith Broadway, West Middlesex Hospital, Harlow and Hertfordshire) covering different geographical areas in London and >12,000 patients. We report the results of 10-year experience of this service and the prevalence of major noninfectious comorbidities, polypharmacy (≥5 medications), and multimorbidity (≥2 non-HIV-related comorbidities) in a cohort of PLWH attending this service. We also describe clinical care pathways established in our center for the assessment and management of major comorbidities in PLWH in line with current BHIVA/EACS guidelines.11,12
Discussion
A demographic shift in PLWH is already visible,5,6 and HIV services must be designed to reflect the changing needs of an aging population living with HIV and overcome a fragmentation of HIV care delivery.44,45 In practice, the prevalence of noninfectious comorbidities is increasing as this population ages leading to frequent referrals to multiple specialist services, adding an economic burden and risking a fragmented care. To deliver an integrated patient care, a multidisciplinary clinic for PLWH older than 50 years was implemented in January 2009.10 The results of a service evaluation after 10 years of experience of this clinic indicate a high prevalence of noninfectious comorbidities that largely concurs with similar studies on this topic.2,3,7
Pathways for the assessment and management of major comorbidities in PLWH were revised according to these data and led to the implementation of the following: (1) a dedicated "aging PLWH" clinical pathway to be introduced into the routine clinical practice in all HIV outpatient services under the remit of CWH; and (2) new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and care of the elderly clinics) to deliver specialized but integrated care to patients in a timely manner. These are multidisciplinary clinics run by an HIV physician in conjunction with specialists in different areas of care delivery using a one-stop clinic approach. The aim is to provide integrated medical advice and joint team decisions in one single patient visit, decreasing delays in treatment initiation and reducing the number of hospital visits. Furthermore, these services provide specialized training to non-HIV physicians on HIV-related care and on the management of age-related diseases to HIV physicians. Referrals to cospecialty clinics can be done by HIV physicians or nurse practitioners or by GPs. Communication with GPs is crucial for the optimal management and follow-up of these comorbidities and to clarify questions about possible concerns around DDIs. A restructuration of HIV health care services is already in place as we believe that HIV patient care in the future will rely on coordinating services to manage HIV-related and nonrelated comorbidities in partnership with other specialties, GPs, care homes, and others. The use of telemedicine services for managing both comorbidities and HIV as a chronic condition could be a way of expanding the access to specialized care by removing geographical barriers and promoting retention in care. While the use of telemedicine has been limited by complex regulations, these services are now widespread as a consequence of the COVID19 pandemic and should be explored as an effective way of delivering specialized care in the future.
Although consistent evidence may be lacking to fully support the hypothesis of premature aging of PLWH, studies have shown that PLWH may present with typical age-related comorbidities 10-15 years earlier than the general population .46 Several HIV-specific and non-HIV factors may contribute to accelerated aging of PLWH, including chronic inflammation and immune senescence, HIV itself, and toxicity associated with long-term cART.47,48 However, there may be potential confounders as PLWH are overexposed to behavioral risk factors (e.g., smoking, alcohol consumption, and recreational drug use) and coinfections (e.g., hepatitis C virus, cytomegalovirus).49,50 We found a high prevalence of cardiometabolic disorders in our cohort including dyslipidemia (50.1%) and hypertension (21.5%), as well as behavioral factors such as smoking (36.9%) and obesity (11.9%). This may indicate the need to introduce lifestyle interventions to reduce modifiable risk factors at an earlier age. On the contrary, it is expected that the number of patients with geriatric syndromes characterized by complex multimorbidities, polypharmacy, and frailty will increase in future years7 as well as the proportion of nursing home residents living with HIV. Early medical interventions are key to improve health outcomes and reduce hospitalizations and mortality. Furthermore, the needs of specific subgroups of PLWH, such as those admitted to long-term care institutions or those with physical and mental incapacities, should be carefully evaluated and a continuous effort to coordinate HIV service providers will be required. In line with this, we have implemented an HIV complex patient virtual clinic, consisting of a multidisciplinary team involving HIV physicians, psychiatric liaison nurses, social care workers, and community nurses with the aim of discussing complex social, psychological, or other health issues that require coordination of care or community HIV nursing input.
This study is limited by its retrospective nature and by the analysis of a single cohort, limiting the generalizability and reproducibility of the results. This is further reduced by the underrepresentation of women and nonwhite race. This study is also limited by the cross-sectional design, and therefore, we could not assess clinical outcomes. Furthermore, we mostly captured the prevalence of comorbidities of interest and may have failed to detect other common comorbidities such as liver disease. Finally, the definition of comorbidities, although standardized in cohort studies, may overestimate disease condition. This is the case for dyslipidemia or hypertension, where use of statins or antihypertensive drugs was used as diagnostic criteria.
Conclusion
The results of our analysis revealed significant rates of non-HIV-related comorbidities in PLWH older than 50 years and underscored the need for restructuring the model of HIV care favoring the prevention of comorbidities to reduce the burden of complex multimorbidity in older people with HIV. Efforts were made to standardize the care and implement clinical pathways targeted to the aging patient into routine HIV clinical practice. Referral pathways and novel HIV cospecialty services offering efficient and multidimensional care were implemented to meet the needs of a population living and aging with HIV.
Materials and Methods
Study design
Retrospective cross-sectional analysis of a cohort of patients attending the HIV over 50 service between January 2009 and January 2019. This study was approved by CWH as a service evaluation to review clinical practice and inform local decision-making. No identifiable clinical data were shared with individuals outside the care team.
The HIV over 50 service
PLWH older than 50 years undergo a two-step multidimensional evaluation and are screened for main age-related comorbidities (i.e., CVD, bone disorders, mental health and neurocognitive impairment, diabetes, hormonal changes, and malignancies). The rationale behind the clinical protocols and routine assessments performed in the over 50 clinic has been previously described.10
Polypharmacy, multimorbidity, and frailty
A systematic review of polypharmacy and potential DDIs between cART and comedications was performed in this clinic, favoring a drug deprescription strategy in the management of polypharmacy whenever possible (Fig. 6).42 In particular, we estimated the anticholinergic burden, since it may predict increased prevalence of side effects, falls, and cognitive decline.8 The overall prevalence of polypharmacy and multimorbidity in our cohort was 46.6% and 69.3%, respectively. Heavy polypharmacy (≥10 medications) was present in 30/744 (7.9%) patients. The most frequently prescribed drug classes were as follows: statins (46.1%), antihypertensives (33.3%), antidepressants (15.9%), and proton pump inhibitors (10.8%).
Frailty assessment was performed in the first clinic visit using the Rockwood Frailty Index.43 Patients with a Rockwood frailty score of 3-4 were referred to the local Living Well pathway to optimize risk factors, improve diet, and exercise. Patients with higher frailty scores were referred to a specialized HIV/geriatric clinic run by HIV specialists together with geriatric consultants (Fig. 6). The aim of this clinic is to recognize early and intervene aggressively to delay or prevent permanent debility and frailty in PLWH. In line with this, mildly and moderately frail patients (Rockwood scores 5-6) are often the patients who benefit the most from this service where interventions are targeted to minimizing risk factors, preventing falls, reducing social isolation, and ultimately delay the progression of frailty.
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