Multimorbidity in elderly people living with HIV: how do general practitioners manage? / Polypathologie des personnes âgées vivant avec le VIH : quelle gestion en médecine générale ?

INTRODUCTION: The occurrence of multimorbidity concerns more and more people living with HIV (PLWHIV) and its frequency increases with age. General practitioners should occupy a central place in the out-of-hospital follow-up of elderly PLWHIV with multimorbidities. Our study aims to understand the actual position of general practitioners and the barriers they encounter in the management of elderly PLWHIV with multimorbidities. METHODS: This sub-study of the ANRS EP66-SEPTAVIH sancillary tudy, which assesses frailty in PLWHIV aged 70 years and over, is based on in-depth interviews with general practitioners and PLWHIV aged 70 years and over. The data were processed manually. Themes and sub-themes were identified and tabulated before being subjected to a cross-sectional thematic analysis. RESULTS: Based on 30 interviews conducted between April 2020 and June 2021 with 10 general practitioners and 20 PLWHIV aged 70 years and over and with multiple diseases, this study identifies the difficulties that general practitioners encounter in fully participating in the care. The follow-up of these patients is characterized by symbolic partitions between groups of professionals: organizational fragmentation between general practitioners and specialists, fear of encroaching on the role of the other health professionals, and frequent absence of formalization of roles in the coordination of care. CONCLUSIONS: In order to promote optimal follow-up and improve the experience of elderly PLWHIV, it is important that the role of each stakeholder be better defined for better shared follow-up.

Introduction: La polypathologie est une problématique de santé qui concerne de plus en plus de personnes vivant avec le VIH (PVVIH) et dont la fréquence augmente avec l'âge. Le recul actuel de l'hospitalo-centrisme devrait amener le médecin généraliste à occuper une place centrale dans le suivi extra-hospitalier des PVVIH âgées et polypathologiques. Notre étude cherche à comprendre la place qu'occupent réellement les médecins généralistes et les barrières qu'ils rencontrent dans la prise en charge des PVVIH âgées et polypathologiques. Méthodes: Nous présentons ici les résultats d'une étude ancillaire d'une précédente recherche (ANRS EP66-SEPTAVIH) qui évalue la fragilité chez les PVVIH âgées de 70 ans et plus. Elle repose sur des entretiens approfondis réalisés auprès de médecins généralistes et de PVVIH âgées de 70 ans et plus. Les données ont fait l'objet d'un traitement manuel et les thèmes et sous-thèmes identifiés ont été classés dans un tableau sous forme de grilles d'être soumis à une analyse thématique transversale. Résultats: À partir de 30 entretiens réalisés d'avril 2020 à juin 2021 auprès de 10 médecins généralistes et 20 PVVIH âgées de 70 ans et plus et polypathologiques, cette étude identifie les difficultés que les médecins généralistes rencontrent pour intervenir pleinement dans la prise en charge de ces patients. Leur suivi est caractérisé par des cloisonnements symboliques entre groupes de professionnels : morcellement organisationnel entre médecins généralistes et spécialistes, peur d'empiéter sur le rôle de l'autre professionnel de santé et absence fréquente de formalisation des rôles dans la coordination des soins. Conclusions: Afin de favoriser un suivi optimal et d'améliorer le vécu des PVVIH âgées, il est important que le rôle de chaque intervenant soit mieux défini pour un meilleur suivi partagé.

Prevalence and risk factors of frailty among adults living with HIV aged 70 years or older.

OBJECTIVES AND DESIGN: Frailty is a phenotype associated with adverse health outcomes in older persons. It has been evaluated mainly in middle-aged persons with HIV (PWH). The French multicenter prospective ANRS EP66 SEPTAVIH study aimed to assess frailty prevalence and risk factors in PWH aged 70 years or older on antiretroviral treatment (ART) for at least 12 months. METHODS: At baseline, Fried frailty phenotype criteria, sociodemographic data, medical/HIV history, functional status, comorbidities, including impaired cognitive function, depression, history of falls, and co-medications were collected. We measured the prevalence of frailty and compared the characteristics of frail versus prefrail and robust participants using univariate (Kruskal-Wallis tests for continuous variables and Chi 2 tests for categorical variables) and multivariate analyses. RESULTS: Five hundred and ten PWH, mostly male (81.4%), were included with a median age of 73 years. The median HIV and ART durations were 22.7 years and 15.7 years, respectively. The prevalence of frailty was 13.5%, and of prefrailty 63.3%. In the multivariate analysis, increasing age [odds ratio (OR) 1.79 for each 5-year increment; 95% confidence interval (CI) 1.32-2.41], deprived socioeconomic status (OR 3.17; 95% CI 1.76-5.70), and multimorbidities (three or more) (OR 2.03; 95% CI 1.06-3.90) were associated with frailty. CONCLUSION: A low prevalence of frailty was reported (13.5%) in PWH aged 70 years or older, whereas two-thirds of them were prefrail. Age, low socioeconomic status, and multimorbidities, but no HIV-related factors, were associated with frailty, suggesting the need to target these factors to help promoting successful aging in this population.

Elevated risk of viral rebound on ART in migrants living in France: role of socioeconomic factors.

BACKGROUND: In Western countries, viral rebound on antiretroviral therapy (ART) appears to occur more frequently in migrants. We aimed to assess the respective roles of socioeconomic factors and migration on viral rebound in people living with HIV (PLHIV) in France. METHODS: We included PLHIV in France, enrolled from 2004 to 2008 in the French ANRS-COPANA cohort, who started a first ART and achieved undetectability (<50 copies/ml) within 1 year. Determinants of viral rebound were assessed using Cox models including geographical origin, HIV transmission group, and clinicobiological and sociodemographic data. RESULTS: Of 499 included individuals, 288 were born in France, 158 in sub-Saharan Africa (SSA) and 53 in another country. Kaplan-Meier probabilities of viral rebound-free survival were similar for men having sex with men (MSM) and heterosexuals born in France, and lower in migrants from SSA or other countries (P<0.001). The crude hazard ratio (HR) of viral rebound was 2.49 (95% CI, 1.59, 3.90) in migrants from SSA and 1.78 (0.94, 3.88) in migrants from other countries compared with MSM born in France. Educational level, financial difficulties and HIV status disclosure had the biggest impact on the difference between the crude and adjusted HRs for viral rebound in migrants. In multivariable analysis, viral rebound was no longer associated with geographical origin, but with protease inhibitor-containing ART, a VACS index ≥35 as a potential indicator of frailty, poor financial status (difficulties or debts) and non-disclosure to friend(s). CONCLUSIONS: Socioeconomic factors affect outcomes on ART, even in the context of free access to HIV care and treatment. Patient-centred strategies should be encouraged with the intervention of social workers to address basic needs and promote social support for more socially vulnerable individuals.

Respective roles of migration and social deprivation for virological non-suppression in HIV-infected adults on antiretroviral therapy in France.

Barriers to achieve sustained HIV virological suppression on antiretroviral therapy (ART) jeopardize the success of the 90:90:90 UNAIDS initiative which aims to end the HIV/AIDS epidemic. In France, where access to ART is free and universally available, we analyze the way in which social determinants of health (i.e. cultural, environmental) and economic factors might influence virological outcomes. A cross-sectional study was performed in two hospitals located in Paris area. All consecutive people living with HIV (PLHIV) on ART for at least 6 months attending the outpatient clinics between 01/05/2013 and 31/10/2014 answered an individual score of deprivation, EPICES, retrieving information on health insurance status, economic status, family support and leisure activity. This score varies from 0 to 100 with deprivation state defined above 30.17. Factors associated with HIV viral load >50 copies/ml were assessed by logistic regression modeling with a backward stepwise selection to select the final multivariable model. Sensitivity analyses were performed using two other thresholds for virological non-suppression (100 or 200 copies/ml). Overall, 475 PLHIV were included (53% male, median age 47 years, 66% not born in France mainly in a sub-Saharan African country). Half of French natives and 85% of migrants were classified as deprived. Median duration on ART was 9.7 years with virological suppression in 95.2% of non-deprived participants and in 83.5% of deprived ones (p = 0.001). The final multivariable model retained ART tiredness, younger age, a previous AIDS event and social deprivation (adjusted Odds Ratio, 2.9; 95%CI, 1.2-7.0) as determinants of virological non-suppression but not migration in itself. When using separate components of EPICES score, reporting economic difficulties and non-homeownership were associated with virological non-suppression. In addition to interventions focusing on cultural aspects of migration, social interventions are needed to help people with social vulnerability to obtain sustained responses on ART.