RESUMO
BACKGROUND: The introduction of antiretrovirals has resulted in a demographic shift with an increasing proportion of people living with HIV older than 50 years and a change in the spectrum of diseases affecting this population. A specialised clinical service dedicated to older people living with HIV was implemented at Chelsea and Westminster Hospital, London, UK in 2009, following training of health-care providers in HIV, ageing, comorbidity, and polypharmacy management. We report the results of a service evaluation reviewing 10 years of activity of this specialised clinic, including lessons to be applied in routine practice. METHODS: We estimated the prevalence of multimorbidity and polypharmacy and described algorithms devised for use across our HIV outpatient services following implementation of the specialised clinical pathway. The service evaluation was approved by our local clinical governance system and data relative to the period 2009-19 were collected on a secured trust database. FINDINGS: Dedicated time was created for senior and junior doctors, a nurse, and a pharmacy to create clinical appointments for older people living with HIV referred by all service care providers. The team would review different clinical scenarios, book follow-up appointments to review results, refer to different specialists or to complex multidisciplinary teams when necessary. 744 people with HIV aged 50 years and older attended our services (93% [691] male, 7·1% [53] female; mean age 56·5 years [SD 5·5]; 84·2% [622] White, 7·5% [56] Black, 0·9% [7] Asian, 7·5% [56] other race or ethnicity). The prevalence of multimorbidity was 69·3% and of polypharmacy was 46·6%. The most common comorbidities were vitamin D deficiency (428 of 690, 62%), dyslipidaemia (373, 50·1%), hypertension (157, 21·5%), depressive or anxious disorders (117, 15·8%), osteoporosis (91, 12·2%), obesity (98, 13·2%), chronic kidney disease (56, 7·5%), and diabetes (43, 5·7%). Patients with dyslipidaemia, osteoporosis, and metabolic disorders were referred to a live well pathway clinic focusing on targeted lifestyle interventions, including diet and physical exercise, under the supervision of a dietician and a physiotherapist. INTERPRETATION: We have described how our HIV over-50 clinic was organised and implemented, and we reported data showing high rates of comorbidities and polypharmacy, which led to the establishment of a specialised care pathway for all HIV care providers and to the implementation of further joint HIV and specialty clinics (cardiology, metabolic, menopause, nephrology, neurology, and geriatric). FUNDING: None.
Assuntos
Dislipidemias , Infecções por HIV , Osteoporose , Idoso , Envelhecimento , Comorbidade , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Osteoporose/epidemiologia , Reino Unido/epidemiologiaRESUMO
Successful management of HIV infection as a chronic condition has resulted in a demographic shift where the proportion of people living with HIV (PLWH) older than 50 years is steadily increasing. A dedicated clinic to PLWH older than 50 years was established at Chelsea and Westminster Hospital in January 2009 and then extended to HIV services across the directorate. We report the results of a service evaluation reviewing 10 years of activities of this clinic between January 2009 and 2019. We aimed to estimate the prevalence of major noninfectious comorbidities, polypharmacy (≥5 medications), and multimorbidity (≥2 non-HIV-related comorbidities) and describe algorithms devised for use in HIV outpatient clinics across the directorate. A cohort of 744 PLWH older than 50 years attending this service were analyzed (93% male; mean age of 56 ± 5.5 years; 84% white ethnicity); 97.7% were on antiretroviral treatment and 95.9% had undetectable HIV-RNA at the time of evaluation. The most common comorbidities diagnosed were dyslipidemia (50.1%), hypertension (21.5%), mental health disorders (depression and/or anxiety disorders, 15.7%), osteoporosis (12.2%), obesity (11.9%), chronic kidney disease (7.5%), and diabetes (5.8%). Low vitamin D levels were found in 62% of patients [43% with vitamin D deficiency (<40 mmol/liter) and 57% with vitamin D insufficiency (40-70 mmol/liter)]. The overall prevalence of polypharmacy and multimorbidity was 46.6% and 69.3%, respectively. This study showed significant rates of non-HIV-related comorbidities and polypharmacy in PLWH older than 50 years, leading on to the implementation of clinical care pathways and new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and geriatric) to improve prevention, diagnosis, and management of major comorbidities in people aging with HIV.
Assuntos
Infecções por HIV , Idoso , Envelhecimento , Instituições de Assistência Ambulatorial , Comorbidade , Estudos Transversais , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Hospitais , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Fármacos Anti-HIV/uso terapêutico , Betacoronavirus/patogenicidade , COVID-19/epidemiologia , Infecções por Coronavirus/epidemiologia , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Pandemias , Pneumonia Viral/epidemiologia , Adulto , COVID-19/prevenção & controle , COVID-19/psicologia , COVID-19/transmissão , Coinfecção , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/psicologia , Infecções por Coronavirus/transmissão , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , HIV/efeitos dos fármacos , HIV/patogenicidade , Infecções por HIV/psicologia , Infecções por HIV/transmissão , Humanos , Masculino , Pandemias/prevenção & controle , Distanciamento Físico , Pneumonia Viral/prevenção & controle , Pneumonia Viral/psicologia , Pneumonia Viral/transmissão , Profilaxia Pós-Exposição/métodos , Profilaxia Pós-Exposição/estatística & dados numéricos , Programas de Monitoramento de Prescrição de Medicamentos , SARS-CoV-2 , Parceiros Sexuais/psicologia , Reino Unido/epidemiologiaRESUMO
A 30-year-old man was admitted to hospital after complaining of a retrosternal burning pain, radiating to the jugular region, and to both upper limbs. An electrocardiography examination showed a ST segment elevation involving the lower-lateral leads. A trans-thoracic ultrasonography showed findings compatible with an acute myopericarditis. All performed serological testings excluded other recent infections with cardiac tropism. Among screening tests, a peripheral lymphocyte subset analysis was performed and an inversion of the CD4/CD8 ratio was found. Therefore, HIV testing was performed and proved positive for HIV-1 antibodies. The discovery of a primary HIV infection with involvement of a vital organ led us to start HAART. On day 20, our patient underwent a right heart catheterization and endomyocardial biopsy. During the following days, the clinical conditions of our patient improved, and a further heart ultrasonography documented a mild pericardial thickening as a result of the recent myopericarditis. Also the evolving changes of ECG were compatible with a benign evolution of myopericarditis. The histopathologic studies revealed a mild fibrosis of the myocardial right ventricular tissue, and inflammatory findings compatible with a recent myocarditis. At the real-time PCR analysis on bioptic sample, only HHV6 DNA and HIV-DNA were reactive. An immunofluorescence staining was performed to highlight the HIV p24 protein and a positive signal was detected in myocardial tissue. Considering the low avidity level of the anti-HIV IgG antibodies and the positivity of HIV-DNA in the endomyocardial tissue, we believe that the clinical manifestation presented can be referred to the recent primary HIV-infection.
Assuntos
Infecções por HIV/diagnóstico , HIV-1 , Miocardite/diagnóstico por imagem , Pericardite/diagnóstico por imagem , Doença Aguda , Adulto , Terapia Antirretroviral de Alta Atividade , Cateterismo Cardíaco , Ecocardiografia , Eletrocardiografia , Infecções por HIV/tratamento farmacológico , Humanos , Imageamento por Ressonância Magnética , Masculino , Miocardite/terapia , Miocardite/virologia , Pericardite/terapia , Pericardite/virologia , Reação em Cadeia da Polimerase em Tempo Real , Resultado do TratamentoRESUMO
Renal toxicity in a 73-year-old male, using tenofovir/emtricitabine as preexposure prophylaxis, is described. Reduced renal reserve, a higher exposure to comedications and comorbidities can present a challenge when assessing the risks and benefits of tenofovir-based preexposure prophylaxis in the ageing population.
Assuntos
Fármacos Anti-HIV/efeitos adversos , Quimioprevenção/efeitos adversos , Emtricitabina/efeitos adversos , Infecções por HIV/prevenção & controle , Nefropatias/induzido quimicamente , Profilaxia Pré-Exposição/métodos , Tenofovir/efeitos adversos , Idoso , Fármacos Anti-HIV/administração & dosagem , Quimioprevenção/métodos , Comorbidade , Emtricitabina/administração & dosagem , Humanos , Nefropatias/patologia , Masculino , Medição de Risco , Tenofovir/administração & dosagemRESUMO
An HIV-infected 49-year-old man was admitted with polyuria, fever, chills and a dull left lumbar pain. Laboratory tests showed increased C-reactive protein while urine analysis and abdomen ultrasound scan were negative. Blood cultures revealed a Salmonella paratyphi B, identified through MALDI-TOF mass spectrometry. Targeted antibiotic therapy with intravenous piperacillin/tazobactam was started and a multi-phase contrast-enhanced abdomen CT-scan was performed at 24 hours from admission showing a saccular aneurysm of the abdominal aorta with a 1 cm penetrating aortic ulcer on posterior wall. The patient underwent emergency vascular surgery at 34 hours from admission for debridement and homo-graft placement of sub-renal aorta, and surgical samples were sent for microbiological analysis. Unfortunately, the patient died on post-surgical day 7 after haemorrhagic shock due to laceration of his graft. Salmonella paratyphi infection can be responsible for sepsis in severely immunosuppressed patients with poorly controlled HIV, requiring careful work-up for cardiovascular involvement.