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Survey in Italy Finds Lack of
Special Care for Elderly With HIV
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International Workshop on HIV and Aging, October 13-14, 2022
By Mark Mascolini for NATAP and Virology Education
Large majorities of health workers from 35 practices across Italy said their clinic had no dedicated HIV care service for people over 65 and could not provide geriatric consultation for these individuals [1]. Among 66 surveyed HIV-positive people over 50 years old, 41% met at least one frailty criterion, 29% had moderate or severe impairment by one standard measure, and 18% fell in the past year.
Giovanni Guaraldi from the University of Modena and Reggio Emilia and colleagues throughout Italy conducted this survey during the week including World AIDS Day (December 1) in 2021. They based their survey on European AIDS Clinical Society (EACS) 2021 HIV guidelines and 2017 guidelines from the Società Italiana di Malattie Infettive e Tropicali (SIMIT). Both guideline sets offer specific statements on models of care for older people with HIV.
The researchers compared EACS and SIMIT guidelines for specific statements on care for older HIV-positive people, including advice on comorbidities, multimorbidity, polypharmacy, frailty, and falls. Then they used statements on which the guidelines agreed to devise a survey for health care workers and people with HIV over 50 years old. Both guidelines cite health-related quality of life as the ultimate goal of clinical care, but neither suggests how to reach that goal in an individual.
Guaraldi and colleagues offered the survey to all HIV clinics in Italy and their HIV patients older than 50 during World AIDS Day week in 2021.Thirty-five clinics and 66 people with HIV responded. Thus the researchers recruited convenience samples that may not represent all HIV clinics in Italy or all their HIV patients over 50.
Among the 35 HIV clinic health care workers who responded, 77% reported no dedicated HIV care service for people older than 65, and 80% reported no access to a geriatric consultation in their clinic. But 83% of health care workers reported offering patients education on HIV and aging, 86% offered long-acting antiretroviral regimens to people over 50, and 66% offered telemedicine visits to the over-50 cohort.
Among the 66 older-than-50 respondents with HIV, 77% were male, 20% female, and 3% transgender. Age averaged 61 years and HIV duration 21 years. Lowest-ever CD4 count averaged 208 and current CD4 count 679. A large majority, 96%, had an undetectable viral load.
While 70% of respondents took a three-drug antiretroviral regimen, 26% took 2 antiretrovirals, and 4% took some other number. Most people, 82%, took a single-tablet regimen. Only 3% said they had a problem taking antiretroviral therapy daily.
While 35% of survey respondents reported they sometimes lacked companionship, 11% said they often did. More than three quarters, 78%, felt they could count on someone close to them in times of need. One in 5 (21%) had faced financial difficulties with health care costs in the past year. (Italy’s National Health Service covers most health care costs of citizens and legal foreign residents. But copayments are required for some services including specialty visits and procedures and some outpatient drugs [2].)
According to a frailty screening and scoring system developed by some of the investigators, 36% of respondents met 1 or 2 frailty criteria, and 5% met more than 2. According to the Duke Activity Status Instrument [3], 42% had mild impairment, 27% moderate impairment, and 2% severe impairment. Four in 10 respondents, 42%, met criteria for optimal health-related quality of life by EQ-5D-5L questionnaire [4]. Almost 1 in 5 respondents, 18%, reported falling in the last year, and 21% reported taking more than 5 drugs beyond antiretrovirals. One quarter of respondents, 24%, said they perceived themselves negatively because of their HIV status.
To provide better care for older people with HIV, the researchers recommended integrating services for comorbidities, frailty, and geriatric syndromes in “a comprehensive geriatric assessment.” They agreed with EACS and SIMIT statements that health-related quality of life “should be the goal of a person-centered approach,” but they stressed that relevant clinical tools must be available and quantitative targets set.
References
1. Guaraldi G, Brogonzoli L, Marchetti G, et al. Aging and HIV: what is the gap between clinical practice and guideline recommendations? International Workshop on HIV and Aging, October 13-14, 2022. Abstract 8.
2. The Commonwealth Fund. International Health Care System Profiles. Italy. https://www.commonwealthfund.org/international-health-policy-center/countries/italy
3. mdcalc. Duke Activity Status Instrument (DASI). https://www.mdcalc.com/calc/3910/duke-activity-status-index-dasi
4. EQ-5D-5L User Guide.https://www.unmc.edu/centric/_documents/EQ-5D-5L.pdf
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