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Health systems must adapt to the special needs
of ageing people with HIV and comorbid diseases
to improve both patient-centred and population-centred health outcomes
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Jepchirchir Kiplagat, Dan N Tran, Tristan Barber, Benson Njuguna, Rajesh Vedanthan, Virginia A Triant, Sonak D Pastakia
Given the burden of HIV and the growing burden of ageing people with HIV, national health policies, strategies, advocacy, and priorities should be set to meet the comprehensive needs of ageing people with HIV, their comorbid conditions, and their ageing needs.
"Health systems must therefore adapt to preventing and managing comorbidities and respond to the social, structural, and economic needs of the ageing HIV population."
In addition to an increase in comorbid conditions, ageing populations are confronted with stigma and discrimination, including ageism, that has resulted in a high prevalence of social isolation and loneliness among older adults (see the second paper in this Series). These challenges are worsened by the lack of intersection of ageing-related and HIV-related social services and support systems. Structurally, health-care providers assume that older adults are not sexually active and, as a result, are less likely to screen them for HIV or offer sexual education (see the first paper in this Series). There are scarce HIV prevention and treatment options, including treatment guidelines for ageing people with HIV.
There is considerable variability in the responsiveness of different types of health-care systems to HIV, chronic disease, and ageing care needs that people living with HIV face. However, one commonality is the lack of, or in some cases minimal, integration of care to meet the needs of ageing people with HIV. The siloed approach to care was designed to reflect the priorities of funders and health-care providers at the start of the HIV epidemic. However, a revised approach should be built that considers the unique needs of this patient group and that prioritises the integration of care and services.
Ageing people with HIV face a confluence of risks posed by both HIV and ageing that increases their risk for ageing-related comorbidities and social issues, requiring enhanced care that meet these needs (see key messages). Although many piecemeal approaches have been developed by health-care systems to catch up to the rapidly evolving needs of ageing people with HIV, there is a pressing need to equitably increase access to comprehensive care for this population worldwide.
In an era when most of the time during clinical visits is spent on chronic disease management and counselling instead of HIV-related issues, a primary care clinician might be the more appropriate provider. Ageing people with HIV have increasing rates of chronic diseases, which primary care providers routinely manage and for which HIV specialists might have less training and experience in managing. Results on the effectiveness of HIV specialists in managing comorbidities has been mixed, with some studies showing a lack of concordance with guidelines for statin prescriptions, and others showing similar rates of NCD screening
As seen through the various solutions used by the different health-care systems mentioned previously, there are still many piecemeal approaches to catchup to the rapidly evolving needs of ageing people with HIV. Overall, common themes that emerge from these approaches reveal the overwhelming need to respond by (1) the creation of a seamless care system, (2) the incorporation of holistic care models to support geriatric patients, patients with HIV, and those with other comorbidities, and (3) training across specialisations to expand the roles of geriatricians, primary care providers, and HIV specialists."
Given the burden of HIV and the growing burden of ageing people with HIV, national health policies, strategies, advocacy, and priorities should be set to meet the comprehensive needs of ageing people with HIV, their comorbid conditions, and their ageing needs.
Adopting a collaborative governance approach to build trust and partnerships from the ministry of health level all the way to local health facilities and the communities in which patients reside, is essential to provide responsive care. Clinical standard operating procedures and guidelines, with consideration for the specific needs of ageing people with HIV should be established and implemented to guide the care provision for this population. In the USA, the Ending the HIV Epidemic: a Plan for America initiative offers a renewed commitment to respond to the HIV epidemic within the country. Political forces should be united to expand the Affordable Care Act and Medicaid and reduce the inequities in HIV care access.
HIV care standards and guidelines through the British HIV Association and a health-care culture that values audit and quality improvement are strong in the UK. This emphasis on audit and quality improvement is a unique strength that can continue to be expounded to ageing people with HIV as national guidelines for care and research in these patients, and their preferences are still limited.
The US health-care system
In the USA, specialised care services are well established and access to a specialised care consultation is available when needed (panel 2). Many patients rely on state and federal safety-net programmes to ensure affordability of antiretroviral therapies (ART). HIV care has historically been delivered by infectious disease-trained and HIV-trained specialists who manage both HIV and primary care needs. Over time, however, discrete HIV care delivery models have emerged. For example, HIV and primary care can be delivered by a single provider (either infectious
disease-trained or internal medicine-trained) or in a model of shared care delivery, with an infectious disease specialist delivering HIV care and a generalist providing primary care. As ART selection and management has been simplified for many patients and viral suppression is more widespread, questions remain as to whether providers for HIV or other infectious diseases should continue to serve as primary care providers or whether primary care providers should provide both primary care and HIV care, with an infectious disease specialist consultation for complicated cases or issues.
In an era when most of the time during clinical visits is spent on chronic disease management and counselling instead of HIV-related issues, a primary care clinician might be the more appropriate provider. Ageing people with HIV have increasing rates of chronic diseases, which primary care providers routinely manage and for which HIV specialists might have less training and experience in managing.
Results on the effectiveness of HIV specialists in managing comorbidities has been mixed, with some studies showing a lack of concordance with guidelines for statin prescriptions, and others showing similar rates of NCD screening.
Conversely, HIV providers have a detailed understanding of the increased risk and novel risk factors at play in comorbidities affecting people living with HIV and of the subtleties of prevention and management, which might differ from those in the non-HIV population. Although guidelines call upon special considerations and awareness in caring for ageing people with HIV few guidelines provide HIV-specific recommendations for the management of comorbidities. In the absence of HIV-specific guidelines for most chronic diseases, HIV primary care guidance relies heavily on general population guidelines. In instances when HIV-specific guidance does exist, such as the American Heart Association's scientific statement on HIV and cardiovascular disease, clinical judgement is required to follow the specific guidance, such as uptitration of the calculated cardiovascular disease risk prediction function based on the presence of risk-enhancing factors such as HIV. Moreover, given increased rates of and differing risk factors for comorbidities in people living with HIV, different thresholds for symptom evaluation and screening might need to be considered. This relative lack of HIV-specific guidance has led to suggestions that an HIV specialist will be helpful in interpreting, adapting, and applying general guidelines to the HIV population. Finally, the question of how to best integrate geriatric services with HIV care is also under active discussion, with several proposed models to optimally address issues including frailty, cognition, polypharmacy, social isolation, and end-of-life care and preferences.
As with NCDs, the management of geriatric syndromes might need to be modified in the HIV setting; one commentary suggested adding a sixth so-called M for HIV-related modifiable factors to the traditional five Ms of geriatrics: mind, mobility, medications, multicomplexity, and matters most.
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February 23, 2022 Lancet Amy C Justice, Matthew B Goetz, Cameron N Stewart, Brenna C Hogan, Elizabeth Humes, Paula M Luz, Jessica L Castilho, Denis Nash, Ellen Brazier, Beverly Musick, Constantin Yiannoutsos, Karen Malateste, Antoine Jaquet, Morna Cornell, Tinei Shamu, Reena Rajasuriar,
Awachana Jiamsakul, Keri N Althof
Summary
As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.
This is the fourth in a Series of four papers on ageing with HIV (papers 1 and 2 appear in The Lancet Healthy Longevity)
Introduction
As HIV enters into its fifth known decade of existence, patients with HIV initially diagnosed early in the epidemic have aged into their 50s and 60s.
The number of ageing people with HIV, that is adults (aged 50 years and older) living with HIV, is increasing and their proportion among total people with HIV is estimated to rise from 28% in 2010, to 73% in 2030 (see the first paper in this Series).
As people age with HIV, however, their needs grow beyond sole management of HIV.
Ageing people with HIV face a confluence of risks posed by both HIV and ageing that increases both their risk for non-communicable diseases (NCDs), and their risk for worse morbidity and mortality from NCDs. HIV infection compounds the risks associated with ageing by independently increasing the risk of frailty, cardiovascular disease, AIDS-defining and non-AIDS-defining malignancies, diabetes, chronic respiratory diseases, pill burden, and provider visits. Globally, metabolic syndrome among older adults living with HIV ranges from 19·7% to 26·6%. Moreover, screening for many NCDs in ageing people with HIV might be hindered by the limited uptake of HIV-specific risk stratification frameworks for diseases, such as cardiovascular disease, which are routinely risk stratified in HIV-negative populations. Additionally, a higher pill burden in multimorbidity and neurocognitive decline might impair understanding of drug regimens, which could lead to increased risk of adverse events due to drug-drug interactions or reduced drug excretion due to ageing-related renal and hepatic dysfunction.
In addition to an increase in comorbid conditions, ageing populations are confronted with stigma and discrimination, including ageism, that has resulted in a high prevalence of social isolation and loneliness among older adults (see the second paper in this Series). These challenges are worsened by the lack of intersection of ageing-related and HIV-related social services and support systems. Structurally, health-care providers assume that older adults are not sexually active and, as a result, are less likely to screen them for HIV or offer sexual education (see the first paper in this Series). There are scarce HIV prevention and treatment options, including treatment guidelines for ageing people with HIV. Despite these risks and care needs, many health-care systems are not optimally designed to care for ageing people with HIV —resulting in episodic and siloed management that potentially places patients at risk of long-lasting complications and death. Health systems must therefore adapt to preventing and managing comorbidities and respond to the social, structural, and economic needs of the ageing HIV population.
Although this general theme applies to the global management of HIV, considerable variability exists in the system-level response to addressing these evolving challenges in different countries. In high-income countries with single payer government systems, HIV care has been integrated into primary care, whereas health systems in the USA typically have assigned most aspects of care for ageing people with HIV to infectious diseases specialists.
As virally suppressed people living with HIV age and experience more age-related comorbidities, many have questioned whether the current setup of care in either health-care system optimally responds to the health needs of ageing people with HIV.
In low-income and middle-income countries, especially in geographical areas with a high burden of HIV, system responses to HIV are influenced by external funders such as the President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Despite several successful care models, which have been developed and implemented to address the HIV-specific needs of populations in these regions, most public sector health systems struggle to address the growing burden of NCDs and age-related syndromes in ageing people with HIV.
Globally, these setting-specific health-care system dynamics have left ageing people with HIV in a precarious position as they navigate their constantly changing health needs.
This narrative review aims to describe health-care system challenges, specifically addressing the needs of ageing people with HIV, by highlighting the current status of care delivery and proposing models of care to meet them. Because of the immense variability between how national health-care systems approach HIV management in different parts of the world, we have broadly divided these systems into three categories: (1) countries that receive a large portion of funding for HIV care through PEPFAR and The Global Fund (PEPFAR-The Global Fund supported countries); (2) the US health-care system; and (3) single payer government systems in high-income countries, relying primarily on the UK as a case example. Although this health system is an overgeneralised division, this approach tries to consider where the bulk of existing research comes from and the settings where HIV burden is geographically located.
There is considerable variability in the responsiveness of different types of health-care systems to HIV, chronic disease, and ageing care needs that people living with HIV face across the different stages of life. Worldwide, health-care systems have undeniably made considerable progress in improving access to HIV care as the basic essential antiretroviral medications, laboratory support, and clinical care are consistently available in all health systems, despite differences in the comprehensiveness and quality of care across different regions.
Organisation of care for ageing populations
PEPFAR-The Global Fund supported countries
HIV programmes in countries supported by PEPFAR-The Global Fund are typically focused on ending the epidemic with integrated and differentiated care models for HIV and NCDs (panel 1; figure 1). Strengths of these programmes include monitoring and evaluating and task-shifting to meet the increasing patient needs. Despite the progress made in the response to HIV, the response to NCDs within PEPFAR-The Global Fund supported countries continues to lag behind the amount of care available for HIV.
For example, many of these countries have the highest rates of early mortality from diabetes and the lowest availability of medications for hypertension.
These same trends extend to the ageing population, who have partial access to their care needs.
This limited access is further complicated by the fragmentation of care when ageing people with HIV receive comprehensive and free care for HIV while being asked to pay user fees for their NCDs.
In places where integrated chronic disease management has been introduced, including within the HIV care platforms, its successful implementation has been hampered by various factors including staff shortages resulting in long waiting times.
Proposed organisation of care within the health-care system to meet the needs of the ageing HIV population
As seen through the various solutions used by the different health-care systems mentioned previously, there are still many piecemeal approaches to catchup to the rapidly evolving needs of ageing people with HIV. Overall, common themes that emerge from these approaches reveal the overwhelming need to respond by (1) the creation of a seamless care system, (2) the incorporation of holistic care models to support geriatric patients, patients with HIV, and those with other comorbidities, and (3) training across specialisations to expand the roles of geriatricians, primary care providers, and HIV specialists.
From a health system perspective, to achieve durable and sustainable success for a condition, which has become a chronic disease, these efforts must be incorporated into a responsive universal health coverage approach to ensure ageing people with HIV have uninterrupted access to the full range of services they will need over the course of their lives. In tracking the attainment of universal health coverage across these three health-care system categorisations, single payer government systems like in the UK (with a universal health coverage score of >90) have made the most progress, whereas high-income countries like the USA still trail behind due to the inequitable access to health services. Countries supported by PEPFAR-The Global Fund have been making strides in advancing the policy landscape to achieve universal health coverage; however, progress on other key indicators used to track attainment of this goal still generally lags behind other regions.
As a result, health systems must adapt to the special needs of ageing people with HIV and comorbid diseases to improve both patient-centred and population-centred health outcomes.
Given the unique contexts and distinguishing social, economic, and health needs within PEPFAR-funded programmes versus non-PEPFAR funded programmes such as single-payer health systems worldwide and within the USA, we propose contextualised strategies to organise care approaches to meet the needs of the ageing HIV population (table), based on the WHO health system strengthening building blocks. With these proposed strategies and examples, we aim to reduce the stigma of HIV management while also improving care. Our goal is for ageing people with HIV to have an easier time accessing the multimorbidity care they need as they face the anticipated progression of chronic diseases and ageing.
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