Monitoring of Older HIV-1-Positive Adults by HIV Clinics in the United Kingdom

A National Quality Improvement Initiative

N Ekong; H Curtis; E Ong; CA Sabin; D Chadwick

Disclosures

HIV Medicine. 2020;21(7):409-417. 

In This Article

Abstract and Introduction

Abstract

Objectives: The aim of the study was to describe a UK-wide process to assess adherence to guidelines for the routine investigation and monitoring of HIV-positive adults aged ≥ 50 years and provide clinical services with individual feedback to support improvement in quality of care.

Methods: The British HIV Association (BHIVA) invited HIV clinical care sites to provide retrospective data from case notes of up to 40 adults aged ≥ 50 years with HIV-1 infection attending the clinic for care during 2017 and/or 2018, using a structured dynamic online questionnaire.

Results: A total of 4959 questionnaires from 141 clinical services were returned. Regarding the key targets specified in the BHIVA monitoring guidelines, 97% of patients on antiretroviral therapy (ART) had had their viral load measured in the last 9 months, or 15 months if on a protease inhibitor, and 94% had had all medications recorded in the last 15 months. Only 67% of patients on ART without cardiovascular disease (CVD) had had a 10-year CVD risk calculated in the last 3 years. It was reported that 80% and 92% had had their smoking status documented in the last 2 years and blood pressure checked in the last 15 months, respectively. HIV services had communicated with the general practitioners of 90% of consenting individuals, but consulted electronic primary care records for only 10%.

Conclusions: Nationally, targets were met for viral load and blood pressure monitoring but not for CVD risk assessment, smoking status documentation and recording of comedication. There was variable performance in relation to other outcomes; adherence and laboratory measurements were carried out more regularly than lifestyle and wellbeing assessments.

Introduction

In 2017, 39% of people seen for HIV care in the UK were aged ≥ 50 years.[1] This proportion is rising as excellent antiretroviral therapy (ART) outcomes continue to contribute to increased life expectancy, and increased HIV testing results in more diagnoses in this age group. While this is welcomed, ageing among people with HIV infection presents increasing scope for non-HIV-related comorbidity and polypharmacy.

Frequently encountered comorbidities in people with HIV infection include cardiovascular disease (CVD), hypertension, dyslipidaemia, renal impairment and osteoporosis;[2,3] regular screening for these conditions is recommended in this population. High rates of isolation and depression have also been recognized in people living with HIV.[4] Screening and identification of any psychological concerns in older people with HIV infection should not be neglected, especially as mental health problems may have a negative impact on ART adherence. Compared with the general population, a higher proportion of people with HIV infection do not have contact with a general practitioner (GP). There are multiple reasons for this, although a concern around HIV-related stigma is likely to play a key role; the 2015 Stigma Survey UK revealed that one in eight HIV-positive participants had avoided seeking health care at their general practice in the previous 12 months when it was required.[5] This group may therefore miss out on opportunities for general health monitoring and modifiable risk assessment, placing an additional burden on HIV clinicians who may be their only health care contact.

Alongside ART prescribed by HIV clinicians, people with HIV infection may receive prescribed comedication from primary care and other specialities. The number of medications taken increases with advancing age.[6] Inadequate communication presents a risk of missed drug–drug interactions, some of which can result in significant morbidity.[6–8] Specialist clinical services can also obtain GP-provided information about medical history, prescriptions and immunizations via the Summary Care Record (SCR), which is accessible via the National Health Service (NHS) data spine, and covers 96% of people in England.[9] This is a useful tool for HIV services to obtain key information about co-prescribed medications.

The British HIV Association (BHIVA) is the leading UK association representing health professionals in HIV care. It has published guidelines for the monitoring of adults infected with HIV-1[10] with measurable targets, alongside standards of care[11] which provide further recommendations for good practice, such as the need for routine GP communication and psychological screening. Following earlier national reviews which found poor rates of recording of CVD and fracture risk assessment[12] and psychological screening,[13] BHIVA sought to review quality of care specifically for older adults, to assess if there had been improvements. This article describes the review process used in the UK and highlights the potential for similar methods to facilitate care quality improvement and prevention of noncommunicable diseases in people with HIV infection in high-, middle- and low-income countries.

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