“Ageing with HIV” is associated with a higher frequency of (1) multimorbidity, possibly attributable to previous toxic exposure to ART and lifestyle factors; (2) polypharmacy due to ART and other medications for co-morbidities, compared with “typical” ageing.[10] It is clear a structural and cultural change in standard patient assessment and transition in care, needs to take place, extending HIV care beyond viral suppression and retention in care. It should be inclusive of the principles of geriatric medicine and include assessments of functional capacity and quality life, now essential to providing adequate care of the ageing person with HIV infection. [3]
The US Department of Health and Human Services “Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV” (followed in Australia) has recently included a section on “HIV and the older person”. This underscores the need for additional medical and social services, particularly in relation to multimorbidity and the need for a collaborative approach between HIV experts, primary care providers and other specialists. [8][28]
The comprehensive geriatric assessment of the medical, physical, mental and social aspects of health enables ascertainment of health status and individual needs in a multi-disciplinary manner. The aim of the assessment is to improve quality of life, extend survival and reduce hospitalisation events. [3]
A practical assessment outline of general and specific considerations to aspire to for the care of older people with HIV infection in ambulatory care, including age-appropriate assessment of co-morbidities, evaluation of geriatric syndromes (falls, incontinence, sleep, confusion, vision/hearing problems, sarcopenia etc), physical function/frailty measurements, neuropsychological and psychological evaluation, evaluation of social problems has been developed by Negredo et al. [4] “Key actions” are also provided, with an emphasis on prevention of chronic conditions, early detection and control, checking for drug-drug interactions, stopping unnecessary drugs (STOP/START criteria) [133, 138] risk factor modification, ensuring maintenance of muscle mass and bone density through exercise and nutrition, cognitive remediation, mental health support if required, and social worker intervention if social problems exist. [4]
Care of the older patient with multimorbidity is best managed with the assistance of a multi-disciplinary team (MDT), where team members are able to understand the future health needs of older people with HIV infection and modify the goals of care to meet those needs. [3] This includes maximising outpatient visits with multiple providers, including primary care physicians, who would ideally lead a diverse team of disciplines, social workers and geriatricians, which may require an overhaul of current services.[3]
Key recommendations
- Endeavour to provide a holistic model of care – with the primary care physician central to a multi-disciplinary team, working to optimize function and quality of life for the ageing HIV population
- Consider the application of a comprehensive geriatric assessment and formal geriatrician referral in older people with HIV infection and multimorbidity who are at risk of, or has any one of the conditions that establish, a ‘geriatric syndrome’.
- Advocate for the ageing HIV population to be included in evidence-based medicine, including interventional clinical trials where they have traditionally been excluded.