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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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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
Published Online:13 Aug 2021
A total of 744 patients attended the over 50 service at the CWH during the study period, predominantly males (93%), with a mean (±SD) age of 56 ± 5.5 years. Eighty-four percent were white, 7.5% black African, and 8.5% from other ethnicities. The mean (±SD) duration of HIV infection was 15.2 ± 8 years and mean CD4 count was 660.8 ± 258 cell/mm3. The majority of patients were on cART (97.7%), with undetectable HIV-RNA (95.9%) at their first clinic visit.
The most common noninfectious comorbidities diagnosed were dyslipidemia (50.1%), hypertension (21.5%), mental health disorders (depression and/or anxiety disorders, 15.8%), osteoporosis (12.2%), obesity (13.2%), CKD (7.5%) and diabetes (5.7%) (Fig. 1).
In our cohort, the prevalence of osteopenia (T-score between -1.0 and -2.5 SD at any site) was 63.7%, whereas osteoporosis (T-score less than -2.5 at any site) was diagnosed in 91 (12.2%) patients, more frequently detected at the spine (Table 3).
• An increased prevalence of testosterone deficiency has been reported in men with HIV compared with men without HIV.27,28 In our cohort, we found a prevalence of biochemical hypogonadism of 18.8%, defined by low serum total testosterone levels (<12 nmol/liter) or low free testosterone levels (<0.225 nmol/liter).29
• In women living with HIV older than 50 years, we routinely assess for the presence of menopausal symptoms and postmenopausal complications such as osteoporosis and CVD. In our cohort, 41/53 women were postmenopausal, 14.6% (6/41) had osteoporosis, and 31.7 (13/41) had 10-year risk of CVD >10% with 19.5% (8/41) showing significant calcification on CACS. A specialized menopause clinic was implemented at the CWH for advice on the management of complex menopausal symptoms, including hormone replacement therapy, nonhormonal treatments (such as antidepressants), and nonpharmacological treatments (such as cognitive behavioral therapy and lifestyle modifications).32
• Treatment with bisphosphonates is recommended in patients with high fracture risk (FRAX score >10%), osteoporosis (T-score less than or equal to -2.5), or osteopenia (T-score less than or equal to -1 and greater than or equal to -2.5) in the presence of risk factors for osteoporosis and fragility fractures.20,21 Patients with high fracture risk/osteoporosis should have their calcium and vitamin D levels assessed and optimized.22 A careful review of cART and comedications is recommended to avoid drugs, for example, tenofovir disoproxil fumarate (TDF) especially in combination with protease inhibitors (PI), that could affect further BMD.23 The recommended duration of bisphosphonate treatment is 3-5 years, after which a reassessment with a BMD scan is recommended. If T-scores remain below -2.5, and/or there are incident vertebral fractures, treatment should continue. If the patient has not experienced fractures before or during therapy and the fracture risk is low, a "drug holiday" can be recommended. Although there is no solid evidence, 1-2 years for risedronate, 3-5 years for alendronate, and 3-6 years for zoledronic acid are suggested. After this time, the patient should be reassessed. If a new fracture is experienced, or fracture risk has increased or BMD remains low (T-score less than or equal to -2.5), bisphosphonate treatment should be resumed.
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
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