Improving Care for People Aging with HIV: A Collaborative Quality Improvement Approach.

Nearly 60% of people with HIV in New York State are over 50 years of age. After town halls and a statewide survey of long-term survivors, older people living with HIV, and their providers, the Quality of Care Program of the AIDS Institute in the New York State Department of Health developed a statewide quality improvement project that aimed to improve screening for functional impairments among people aging with HIV. Thirteen sites reported outcomes of a pilot project using a modification of the World Health Organization's Integrated Care of Older People (ICOPE) intrinsic capacity screen in small scale, short cycle tests of change. A total of 1,629 people were found to be eligible for screening, and of these, 638 people were screened. Both clinical and non-clinical sites were able to identify significant areas of need. Positive screens ranged from a low of 17% for the identification of hearing issues to 49% for vision concerns. Only 11% of people with memory or nutritional concerns were referred for services; hearing loss was the domain with the largest number of referrals, at 27%. Although in many cases, when referrals were not made, patients/clients were already under care for the identified functional deficit, in other cases no services were available for referral or patients/clients declined to use the offered service. Sites also responded to the findings of the screen by initiating process changes, and many reported continuing to screen for functional impairments after the close of the pilot. The modified ICOPE screen is still in use in sites throughout the state. This pilot demonstrated that a collaboration between people with lived HIV experience, the New York State Department of Health, clinicians, and service providers could result in improved quality of care for people aging with HIV.

Using Community-Based Participatory Research to Develop Care Recommendations for People Aging With HIV.

Background and Objectives: Over 50% of New Yorkers living with human immunodeficiency virus (HIV) are 50 years old or older, and the emotional and physical consequences of being a long-term survivor are significant. This study aimed to identify the practical needs of long-term survivors and older people with HIV (consumers) in New York State and develop recommendations addressing those needs. Research Design and Methods: The HIV + Aging/LTS/Perinatally Diagnosed Subcommittee of the Consumer Advisory and Quality Advisory committees in the New York State AIDS Institute used community-based participatory research (CBPR) methods to design a statewide survey about the care needs of consumers in New York State. This survey, open to consumers, clinicians, and supportive services providers, was launched in June 2021 using Qualtrics. Participants provided demographic data and chose the 3 most important barriers and recommendations from each of 10 categories of issues affecting health care and supportive services. Consumers provided information about their HIV diagnosis and other health conditions. Responses were characterized using basic descriptive statistics. Results: Participants included 124 consumers from 26 counties, 20 clinicians, and 24 supportive service providers. Among consumers, 67% were cisgender men, 27% were African American, and 65% were both long-term survivors and older people with HIV. On average consumers had been diagnosed with HIV for 27 years. Participants were concerned with clinical care coordination, housing needs, cultural representation in mental health services, and financial support of consumers. Discussion and Implications: CBPR is an effective approach to developing consumer-generated recommendations to improve HIV care for long-term survivors and older people with HIV. Town hall formats informed survey design, enabled broad coverage of topics, and ensured that focus remained on priorities most important to consumers. The first quality initiative arising from the study was a routine screening of long-term survivors of HIV to identify functional decline and enhance referral pathways and care linkages.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Plasma extracellular vesicles and cell-free mitochondrial DNA are associated with cognitive dysfunction in treated older adults with HIV.

Extracellular vesicles (EVs) are nanoparticles with a role in intercellular communication. Cell-free mitochondrial DNA (cf-mtDNA) has been associated with cognitive dysfunction in people with HIV (PWH). We conducted a nested case-control study to test the hypothesis that plasma EVs are associated with cf-mtDNA and cognitive dysfunction in older PWH. A machine learning-based model identified total EVs, including select EV subpopulations, as well as urine cf-mtDNA and 4-meter walk time carry power to predict the neurocognitive impairment. These features resulted in an AUC-ROC of 0.845 + / - 0.109 (0.615, 1.00).

Pyogenic brain abscess associated with an incidental pulmonary arteriovenous malformation.

Pulmonary arteriovenous malformations (PAVMs) are rare and often asymptomatic vascular anomalies that can be associated with serious neurological consequences due to right-to-left shunting. We report a case of a woman in her 80s without substantial medical history who presented with a headache, weakness and personality changes, and was found to have a pyogenic brain abscess requiring emergent neurosurgical evacuation. The abscess grew oral flora, suspected to have reached the brain via an incidentally discovered PAVM. With drainage and antibiotics, the patient achieved a full recovery and the PAVM was embolised. To our knowledge, this is the oldest presentation of a PAVM-associated brain abscess in the published literature. Older patients may present without the typical signs and symptoms of a given illness, which complicates accurate diagnosis and treatment. Primary care physicians can help facilitate timely care and positive clinical outcomes.

Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV.

OBJECTIVE: People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH. METHODS: We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models. RESULTS: PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes. CONCLUSIONS: Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.

Choices and Outcomes of the Oldest Old Admitted During the First Wave of COVID-19 in New York City.

Objectives: Morbidity and mortality are higher in older adults with COVID-19, but their decisions about aggressive care, severity of disease, and outcomes during the first surge in New York City are not well characterized. We sought to determine if the oldest patients chose intubation and comfort care at different rates compared to younger geriatric patients. We also studied outcomes among patients admitted with severe disease and those who chose aggressive versus comfort care. Methods: This retrospective analysis used electronic health record data from patients 65 years and older at two medical centers in New York City admitted between 3/5/2020 and 5/15/2020. The primary outcome was comfort care orders, and secondary outcomes included death, palliative care consultation, goals of care discussion, code status, and ventilator weaning. Results: Of the 854 patients, 214 were in the oldest old (OO, age > = 85) group, 269 middle old (MO, age 75-84), and 371 young old (YO, age 65-74). Among those with serious disease, the OO were more likely to choose comfort care (45% vs. 21% MO and 6.8% YO), less likely to be intubated (17% vs. 37% MO and 44% YO), more likely to have a palliative care consult, more likely to be DNR/DNI on admission (60% vs. 17% MO and 9.3%% YO), and more likely to die during admission (65% vs. 42% MO and 21% YO) (all p-values < 0.001). Of all 216 intubated patients, 78% of the OO died, versus 66% of the MO and 36% of the YO (p = <0.001). Conclusions: Adults 85 and above admitted with COVID-19 were more likely to forego intubation and die with comfort-based care. Irrespective of intubation choice, patients 85 and older had a markedly poorer prognosis than other cohorts over 65.

Plasma Cell-Free Mitochondrial DNA as a Marker of Geriatric Syndromes in Older Adults With HIV.

BACKGROUND: Older people with HIV experience more comorbidities and geriatric syndromes than their HIV-negative peers, perhaps due to residual inflammation despite suppressive antiretroviral therapy. Cell-free mitochondrial DNA (cfmtDNA) released during necrosis-mediated cell death potentially acts as both mediator and marker of inflammatory dysregulation. Thus, we evaluated plasma cfmtDNA as a potential biomarker of geriatric syndromes. METHODS: Participants underwent the Montreal Cognitive Assessment (MoCA), frailty testing, and measurement of plasma cfmtDNA by qPCR and inflammatory markers including C-reactive protein, interleukin-6 (IL-6), interferon gamma, and tumor necrosis factor alpha in this cross-sectional study. RESULTS: Across 155 participants, the median age was 60 years (Q1, Q3: 56, 64), one-third were female, and 92% had HIV-1 viral load <200 copies/mL. The median MoCA score was 24 (21, 27). The plasma cfmtDNA level was higher in those with cognitive impairment (MoCA <23) ( P = 0.02 by the t test) and remained significantly associated with cognitive impairment in a multivariable logistic regression model controlling for age, sex, race, CD4 T-cell nadir, HIV-1 viremia, and depression. Two-thirds of participants met the criteria for a prefrail or frail state; higher plasma cfmtDNA was associated with slow walk and exhaustion but not overall frailty state. Cognitive dysfunction was not associated with C-reactive protein, IL-6, interferon gamma, or tumor necrosis factor alpha, and frailty state was only associated with IL-6. CONCLUSIONS: Plasma cfmtDNA may have a role as a novel biomarker of cognitive dysfunction and key components of frailty. Longitudinal investigation of cfmtDNA is warranted to assess its utility as a biomarker of geriatric syndromes in older people with HIV.

Strengths and Challenges of Various Models of Geriatric Consultation for Older Adults Living With Human Immunodeficiency Virus.

As care of persons living with human immunodeficiency virus (HIV; PWH) has transitioned from management of opportunistic infections to management of conditions associated with older age, new models of geriatric consultation are needed. The authors, who represent 9 clinics across North America and the United Kingdom, provided their insights on models of geriatric consultation for older PWH. Three models of geriatric consultation are delineated: outpatient referral/consultation, combined HIV/geriatric multidisciplinary clinic, and dually trained providers within 1 clinical setting. A patient-centered approach and the use of expertise across disciplines were universally identified as strengths. Logistical barriers and the reluctance of older PWH to see a geriatric care provider were identified as barriers to implementing these models. Although the optimal model of geriatric consultation depends on a region's resources, there is value in augmenting the training of infectious disease providers to include principles of geriatric care.

Using Focus Group Feedback to Identify Patient-Centered Initiatives for Older Persons with HIV.

Objectives: This study assessed how few community-based programs target older people living with HIV.Methods: We conducted four focus groups comprised of people 50 and older with HIV (N = 32; gay/bisexual men, heterosexual men, women, and Spanish-speakers) to inform HIV program development by exploring the services in which participants were actively involved, along with the services they wanted to receive.Results: Using inductive thematic qualitative analysis, four themes were identified pertaining to program development: (a) types of currently utilized HIV service organizations; (b) dissatisfaction with HIV programming and services; (c) participants' preferred programming, courses, groups, or activities; and (d) desire to serve as peer mentors.Conclusions: Results highlight the need for community-based organizations to address social engagement and isolation among older people living with HIV.Clinical implications: These findings exemplify the need for programs to be specifically designed for OPH, and created with the primary goals of socialization and helping develop social support networks.

Links Between Inflammation, Mood, and Physical Function Among Older Adults With HIV.

OBJECTIVES: People living with human immunodeficiency virus (PLWH) treated with antiretrovirals have life spans similar to their HIV-negative peers. Yet, they experience elevated inflammation-related multimorbidity. Drawing on biopsychosocial determinants of health may inform interventions, but these links are understudied in older PLWH. We investigated cross-sectional relationships between psychosocial factors (mood, loneliness, and stigma), inflammatory markers, and age-related health outcomes among 143 PLWH aged 54-78 years. METHOD: Participants provided blood samples for serum cytokine and C-reactive protein (CRP) analyses, completed surveys assessing psychosocial factors and health, and completed frailty assessments. Regression models tested relationships between key psychosocial-, inflammation, and age-related health variables, adjusting for relevant sociodemographic and clinical factors. RESULTS: Participants with more depressive symptoms had higher composite cytokine levels than those with fewer depressive symptoms (ß = 0.22, t(126) = 2.71, p = .008). Those with higher cytokine levels were more likely to be prefrail or frail (adjusted odds ratio = 1.72, 95% confidence interval = 1.01-2.93) and reported worse physical function (ß = -0.23, t(129) = -2.64, p = .009) and more cognitive complaints (ß = -0.20, t(129) = -2.16, p = .03) than those with lower cytokine levels. CRP was not significantly related to these outcomes; 6-month fall history was not significantly related to inflammatory markers. DISCUSSION: Novel approaches are needed to manage comorbidities and maximize quality of life among older PLWH. Illustrating key expected biopsychosocial links, our findings highlight several factors (e.g., depressive symptoms, poorer physical function) that may share bidirectional relationships with chronic inflammation, a key factor driving morbidity. These links may be leveraged to modify factors that drive excessive health risk among older PLWH.

Childhood sexual abuse history amplifies the link between disease burden and inflammation among older adults with HIV.

As they age, people living with HIV (PLWH) experience greater rates of inflammation-related health conditions compared to their HIV-negative peers. Because early life adversity can exaggerate proinflammatory effects of later physiological challenges, inflammation may be higher among PLWH with these combined risks, which could inform intervention approaches to mitigate multimorbidity. In this cross-sectional analysis, we investigated individual and combined effects of childhood sexual abuse (CSA) history and physiological burden (Veterans Aging Cohort Study Index scores) on serum cytokine and C-reactive protein (CRP) levels among PLWH. Participants (n â€‹= â€‹131; age 54 and older) were patients at an outpatient HIV clinic who completed a psychosocial survey and biomedical research visit as part of a larger study. 93% were virally suppressed, and 40% reported experiencing sexual abuse in childhood. Composite cytokine levels (summarizing IL-6, TNF-α, IFN-γ), CRP, and disease burden did not differ significantly between those who had a history of CSA and those who did not. Participants with greater disease burden had higher composite cytokine levels (r â€‹= â€‹0.29, p â€‹= â€‹0.001). The disease burden by CSA interaction effect was a significant predictor of composite cytokine levels (but not CRP), and remained significant after controlling for age, sex, race, BMI, anti-inflammatory medication use, selective serotonin reuptake inhibitor use, depressive symptoms, and smoking status (F(1, 114) â€‹= â€‹5.68, p â€‹= â€‹0.02). In follow-up simple slopes analysis, greater disease burden was associated with higher cytokine levels among those with CSA history (b â€‹= â€‹0.03, SE â€‹= â€‹0.008, p<0.001), but not among those without CSA history. Further, in the context of greater disease burden, individuals with a CSA history tended to have higher cytokine levels than those without a CSA history (b â€‹= â€‹0.38, SE â€‹= â€‹0.21, p â€‹= â€‹0.07). These data suggest that the physiological sequelae of childhood trauma may persist into older age among those with HIV. Specifically, links between physiological burden and inflammation were stronger among survivors of CSA in this study. The combined presence of CSA history and higher disease burden may signal a greater need for and potential benefit from interventions to reduce inflammation, an area for future work.

Current Considerations for Clinical Management and Care of People with HIV: Findings from the 11th Annual International HIV and Aging Workshop.

The number of people with HIV (PWH) aged 50 years or older continues to steadily increase. The convergence of age- and HIV-related complications in these individuals presents a challenge for both patients and clinicians alike. New findings continue to emerge, as numerous researchers evaluate the combined impact of these two factors on quality of life, physiological systems, and mental health in PWH. Since its first occurrence in 2009, the International Workshop on HIV and Aging has served as a multidisciplinary meeting to share basic biomedical data, clinical trial results, treatment strategies, and epidemiological recommendations, toward better understanding and outcomes among like-minded scientific professionals. In this article, we share a selection of key findings presented in plenary talks at the 11th Annual International Workshop on HIV and Aging, held virtually from September 30, 2020 to October 2, 2020. We will also address the future directions of HIV and aging research, to further assess how the aging process intersects with chronic HIV.

Cross-sectional study of correlates and prevalence of functional and high-risk multimorbidity in an academic HIV practice in New York City.

OBJECTIVES: People with HIV have high levels of multimorbidity, but studies often focus on high-risk comorbidities such as hypertension or coronary artery disease. We examined both high-risk and functional comorbidities in an ethnically diverse clinic population to compare the prevalence of comorbidities and different patterns of multimorbidity. DESIGN: Retrospective cross-sectional study. SETTING: University-based primary care HIV clinic with two locations in New York City. PARTICIPANTS: Patients who had been seen by a physician at least once between 1 June 2016 and 31 May 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: Data regarding demographics, diagnoses and lab values were downloaded in a one-time data import from the electronic medical record. Comorbidities were classified as high-risk (with major impact on mortality) or functional (with major impact on function), and multimorbidity was determined for both classes in the total sample of 2751. Factors associated with high-risk and functional multimorbidity were determined first through bivariate analysis and then through multivariable median regression in 2013 patients with complete data. RESULTS: Median age was 52 years (IQR 43-59). Cisgendered women comprised 24.6% of the sample, and 31.7% were African-American. Both functional and high-risk comorbidities were common and risk increased with age. Among those 75 and older, median number of both functional and high-risk comorbidities was 3 (IQR 2-4). High-risk comorbidities were associated with age (p<0.001), more years with an HIV diagnosis (p<0.001) and being an African-American (p<0.001). Associated with a higher number of functional comorbidities were age (p<0.001), being a cisgender female (p<0.001), being Hispanic (p=0.01) and more years with an HIV diagnosis (p<0.001). CONCLUSIONS: Comorbidities with functional impact increase with age in parallel to those with a more direct impact on mortality and should be assessed and monitored, especially as the population with HIV ages.

Urine Cell-Free Mitochondrial DNA as a Marker of Weight Loss and Body Composition in Older Adults With HIV.

BACKGROUND: Older adults with HIV (OAH) experience more comorbidities and geriatric syndromes than their HIV-negative peers, perhaps because of chronic inflammation. Cell-free mitochondrial DNA (cfmtDNA) released from cells undergoing necrosis-mediated cell death potentially acts as both a mediator and marker of inflammatory dysregulation. We hypothesized that urinary cfmtDNA would be associated with frailty, body composition, and fall history in OAH. METHODS: OAH completed frailty testing, a psychosocial survey, body composition assessment, and measurement of urine cfmtDNA and urine albumin:creatinine in this cross-sectional study. Urine cfmtDNA was measured by quantative polymerase chain reaction and normalized to urinary creatinine. RESULTS: Across 150 participants, the mean age was 61 years (SD 6 years), half identified as Black, one-third were women, and 93% had HIV-1 viral load <200 copies/mL. Two-thirds met criteria for a prefrail or frail state. Those with unintentional weight loss had higher urine cfmtDNA concentrations (P = 0.03). Higher urine cfmtDNA was inversely associated with the skeletal muscle index (ß = -0.19, P < 0.01) and fat mass index (ß = -0.08, P = 0.02) in separate multiple linear regression models adjusted for age, sex, and presence of moderate-severe albuminuria. CONCLUSIONS: In this cross-sectional study of OAH, higher levels of urine cfmtDNA were more common in subjects with less robust physical condition, including unintentional weight loss and less height-scaled body mass of fat and muscle. These findings suggest urine cfmtDNA may reflect pathophysiologic aging processes in OAH, predisposing them to geriatric syndromes. Longitudinal investigation of urine cfmtDNA as a biomarker of geriatric syndromes is warranted.

Aging-Related Concerns of People Living with HIV Referred for Geriatric Consultation.

PURPOSE: People with HIV (PWH) are living longer lives and likely experiencing accentuated aging. Comprehensive geriatric assessment (CGA) has been proposed as a way to identify and help meet each individual patient's needs. PATIENTS AND METHODS: We performed a retrospective review of the results of CGA in an HIV clinic in New York City. CGA included assessment of basic and instrumental activities of daily living, screens for depression, anxiety, frailty, cognition, and quality of life, along with general discussion of concerns and goals. We compared the group of PWH referred for CGA to those of comparable age who were not referred to determine the factors that were associated with referral. We carried out a descriptive analysis of those undergoing CGA, along with regression to determine factors associated with poorer PHQ-2 depression scores and higher VACS score. RESULTS: A total of 105 patients underwent full CGA during the study period. Mean age of referred patients was 66.5 years, ranging from 50 to 84 years (SD 7.99). More than 92% were virally suppressed. Compared with their non-referred counterparts over 50, referred patients were older and had more functional comorbidities like cerebrovascular disease, neuropathy, and urinary incontinence. More than half complained of fatigue, and 2/3 noted poor memory. Almost 60% were frail or prefrail. Ninety patients were asked about their goals, and the most commonly cited were related to health or finances; fifteen patients were unable to articulate any goals. Having fewer goals and noting weight loss or fatigue were predictive of higher scores on the PHQ-2 depression screen. CONCLUSION: Although most older PWH undergoing CGA can manage their ADL, many have concerns and deficits beyond their comorbidities. CGA offers an important window into the psychosocial concerns and needs of older PWH.

Gait Speed Is Associated with Cognitive Function among Older Adults with HIV.

Objectives: To determine links between objectively and subjectively measured physical function and cognitive function among HIV-positive older adults, a growing yet understudied group with elevated risk for multimorbidity. Methods: At a biomedical research visit, 162 participants completed objective tests of gait speed (4-m walk), grip strength (dynamometer), and cognitive function (Montreal Cognitive Assessment, MoCA) and reported their well-being (Medical Outcomes Study-HIV survey). Results: Those with faster gait speed had better overall cognitive function than those with slower gait speed (b = 3.98, SE = 1.30, p = .003) in an adjusted regression model controlling for age, sex, race, height, preferred language, and assistive device use. Grip strength was not significantly associated with overall cognitive function. Self-rated cognitive function was weakly related to MoCA scores (r = .26) and gait speed (r = .14) but was strongly associated with emotional well-being (r = .53). Discussion: These observed, expected connections between physical and cognitive function could inform intervention strategies to mitigate age-related declines for older adults with HIV.