| |
Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months in Nursing Homes in USA
|
| |
| |
This is exactly part of the reason a more detailed in depth & broad discussion of aging & HIV is critical now by all including we the older PLWH should be included in these discussions. This mistreatment calls for an official investigation by the NIH & Congress.
Jules Levin
Use of antiretroviral therapy in nursing home residents with HIV
Download PDF here
Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months of observation.
These findings suggest that low rates of ART use may be partially due to inexperience in HIV care in some facilities and/or providers, a serious deficit in the quality of HIV care in NHs, which could impair people's quality of life and result in complications and progression. Evidence-based interventions that improve providers' awareness of appropriate HIV care or identify older patients who are still eligible for ART treatment are urgently needed. Our findings also raise broader questions about appropriate access to specialty care for persons in NHs.
These residents were followed for an average of 11.6 [standard deviation (SD): 11.7; range: 1-48] months. Overall, 38.1% of our study population died during the follow-up, 8.5% died within 180 days, another 9.9% died between 180 and 365 days, and 19.7% died at least 1 year after the index date. In our study cohort, only 1507 of 4171 PLWH (36.1%) received an ART regimen during the follow-up (Tables 1 and S1).
Rates of non-ART use did not differ significantly by residents' end-of-life status, with 65.4% of those who were at end-of-life (i.e., died within 180 days) versus 68.0% of those who were alive for at least 2 years did not receive ART (p = 0.21, Figure 1).
In this national cohort, nearly two-thirds of long-stay NH residents with HIV did not receive an ART regimen during an average observation period of 1 year. High rates of non-ART use put patients at risk for decline in immune function, progression of clinical disease, and premature death. It also increases the risk of HIV transmission to others. Our findings show that the care of long-stay NH residents does not align with national treatment guidelines that recommend ART for everyone with HIV.2, 24 The rate of non-use of ART in our study cohort (∼64%) was much higher than the rates reported previously (21% ∼ 36%).8, 9 Several differences in study methods may explain these discrepancies. First, in the two previous studies, concurrent ART use was used to define the study population; we used only diagnosis codes to avoid biasing our study sample toward those with ART use. Second, the previous studies defined ART use as any ART prescription. In contrast, we counted only valid ART regimes as constituting ART use. Note that when one of the previous papers examined only “preferred” ART regimens, their findings were very similar to ours.9 Additionally, the one previous study that looked only at long-stay residents, making it directly comparable to our study, included only 694 patients,8 as compared with 4171 PLWH in our study.
There are several study limitations. We did not have access to clinical information such as viral loads and CD4+ cell counts. However, ART has been universally recommended for the treatment of HIV since 2013,2 so based on this, all or most PLWH in NHs should be receiving ART. We also do not have access to patient preferences, though we doubt that the majority of long-stay PLWH were offered and declined ART. Finally, our analyses tested associations, and the relationships that we demonstrated may not be causal.
In conclusion, nearly two-thirds of the PLWH in NHs across the United States did not receive ART during an average follow-up of 12 months, a serious deficit in the quality of HIV care in NHs, which could impair people's quality of life and result in complications and progression. Evidence-based interventions that improve providers' awareness of appropriate HIV care or identify older patients who are still eligible for ART treatment are urgently needed. Our findings also raise broader questions about appropriate access to specialty care for persons in NHs.
Use of antiretroviral therapy in nursing home residents with HIV
25 March 2022
Abstract
Background
Antiretroviral therapies (ARTs) are essential HIV care. As people living with HIV age and their presence in nursing homes (NHs) increases, it is critical to evaluate the quality of HIV care. We determine the rate of ART use and examine individual- and facility-level characteristics associated with no ART use in a nationally representative long-stay NH residents with HIV.
Methods
This retrospective cohort study included all long-stay Medicare fee-for-service NH residents (2013-2016) with HIV who had a valid Minimum Data Set assessment. Residents were followed from long-stay qualification until death, Part D disenrollment, transfer from long-term care to another healthcare setting, or December 31, 2016. We identified individual and facility characteristics that were associated with non-use of ART using generalized estimating equation logistic regression.
Results
Exactly 4171 eligible HIV+ residents from 2459 NHs were included in our study. Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months of observation. Older age, females, white race, receipt of Medicare skilled nursing benefits, and some major cardiometabolic comorbidities and mental health conditions were associated with non-ART use. Rates of non-ART use did not vary significantly by residents' end-of-life status (p = 0.21). Residents in facilities with a higher HIV concentration [adjusted odds ratio (adjOR) 3.42; 95% confidence interval (CI) 2.13-5.48] and an AIDS unit (adjOR 2.51; 95% CI 1.92-3.30) had higher odds of using an ART.
Conclusions and Implications
The rate of ART use by HIV+ long-stay NH residents was low. Facilities' experience with HIV played an important role in ART receipt. Interventions to improve rates of ART use in NHs are urgently needed to ensure optimal health outcomes.
Key points
•Approximately two-thirds of people living with HIV who resided in nursing homes in the United States did not receive HIV drug therapies during an average of 12 months observation;
•Residents in nursing facilities with a higher HIV concentration and an AIDS unit had significantly higher odds of receiving HIV drug therapies.
•Evidence-based interventions that improve providers' awareness of appropriate HIV care or identify older patients who are still eligible for ART treatment are urgently needed.
Why does this paper matter?
Inadequate antiretroviral therapy for people with HIV has implications for disease progression, impaired quality of life, and increased risk of death.
|
|
| |
| |
|
|
|
