Click here for a complete list of CME opportunities.
HIV providers in the current era contend with tremendous variability in the health of older persons with HIV/AIDS. Many of us care for HIV-infected patients in their 70’s who are robust, have had an excellent response to antiretroviral therapy (ART), and are living active and fruitful lives. For many of these patients, HIV infection is their only health problem, and not much of a problem at that. At the same time, we care for HIV-infected patients in their 50’s with substantial multi-morbidity including cognitive and/or functional disability. For this latter group, treatment strategies must be considered carefully and individualized; each patient is unique, and will require an individualized care approach that may not reflect the dictates of multiple guidelines.
For those of us who teach, we need to convey those clinical pearls about caring for old and young patients who present with advanced HIV infection and its complications harkening back to the pre-ART era. We must also teach them about our patients who have been diagnosed, are on ART for a couple of decades and are now having health problems related to a long history of variably controlled HIV infection as well as aging.
The issues of multi-morbidity are critically important for an individual patient with several serious health conditions, of which HIV may only be one. HIV may well be the least important condition. It may be even more compelling from the broader view of providing care to populations of patients, and a health system’s capacity to do this. Busy providers are well aware that there is not enough time during the day for a typical physician to do all recommended preventive processes for a typical panel of patients, let alone management of a typical panel’s burden of chronic diseases–multimorbidity.
We continue to struggle to determine which parts of a treatment plan are most important, and have the highest priority This triage process needs to be based on the applicability of the evidence, the actual absolute risk reduction observed in studies, the time needed to treat in order to observe this benefit, and the individual’s values and preferences. The patient’s values and preferences are critical on several counts: 1) what are the most important outcomes for the patient, 2) what burdens are they willing to endure in order to achieve those outcomes, 3) what are their preferences regarding the potential harms of interventions, and 4) how does the level of uncertainty regards the reported benefits of a treatment affect their decision-making process. This is the very basis of patient-centered care.
Reviews of clinical practice guidelines for many common chronic diseases demonstrate that such strategies rarely consider the impact of other co-morbid conditions for older patients making it difficukt to develop treatment priorities. Often missing are considerations of issues pertinent to older adults or to people with co-morbidity: describing the target population for recommendations, reviewing the quality of evidence for older patients or patients with co-morbidity, addressing time needed to treat in order to observe benefit, the trade-offs between short and long-term goals, treatment burden, and patient preferences. Methods to tailor treatment and prevention strategies based on presence of multi-morbidity are emerging. Yet the evidence supports the view that for some clinical situations, our ability to optimize individualize medical decision making for older adults with differing patterns of co-existing conditions is not yet attainable. Among older patients, there is increasing evidence that symptoms or syndromes that are not a disease per se may be the most important to the patient (such as falls, disability).
There are key concepts evolving from the literature on other co-morbid conditions (or multi-morbidity?) that may have relevance to the management of HIV in older adults. A framework for considering co-morbidity in patients with diabetes postulated that it may be worthwhile to determine whether there was a dominant condition. This dominance may arise from the condition being newly diagnosed, life threatening, and so serious that it eclipses the management of other conditions. In the absence of a dominant condition, it may be worthwhile to consider whether or not co-morbid conditions share an underlying pathophysiology and are likely to be part of a shared management plan (concordant) or not (discordant). It may also often be relevant to patients whether the co-morbid condition is symptomatic or asymptomatic.
Finally, there is emerging literature supporting the view that the treatment of some co-morbid conditions in an integrated manner may improve the outcomes for both conditions. For example, the use of buprenorphine in primary care HIV clinics improves substance abuse outcomes and adherence to medical visits, which is associated with better HIV outcomes. Directly observed ART in methadone clinics may also improve HIV outcomes. There is evidence suggesting that an integrated approach to diabetes and depression may improve outcomes for both. In HIV patients with depression there is some evidence that an integrated approach with cognitive behavioral therapy can lead to improved adherence.
Because new information is becoming available rapidly in this evolving field, we continue to work on how to best disseminate updates and state-of-the-art clinical information on managing the older patient with HIV infection. Standard publication tends to “fix” information in time and substance, which does not lend itself well to this consensus project. Consequently, we hope you will avidly participate in all efforts that foster amendment and updating as new medical information becomes available to improve the care of older persons with HIV infection. We invite, we encourage your comments. Our aim is to create a dialogue which will benefit our patients.
J Appelbaum MD and W McCormick MD
Purpose of this Program: The AAHIVM, ACRIA and AGS (collectively, the “Sponsors,” “we” or “us”) are sponsors of this Website and through it seek to address the unique needs and challenges that older adults of diverse populations living with HIV face as they age. However, the information in this Website is not meant to supplant the advice provided in a doctor-patient relationship.
General Disclaimer: HIV-Age.org is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided through HIV-Age.org should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you have or suspect you may have a health problem, consult your health care provider.