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Black Africans who are Ageing with HIV need better assessment for co-morbidities

Updated: Jul 2, 2019

By Denis Onyango

Black African patients who are aging with HIV need better support to understand and manage the risk and onset of HIV related co-morbidities, a recent survey has shown. Africa Advocacy Foundation surveyed over 237 black African patients living and ageing with HIV as part of its AFYA HIV Ageing project which largely showed that that older HIV patients from black and ethnic minority backgrounds exhibited multiple risk factors and or had comorbidities associated with HIV including diabetes, kidney disease, cardiovascular disease, depression among others and also reported poorer quality of life outcomes.

The web and iPad based survey, which was co-produced with the involvement of by patients and HIV clinicians involved 237 HIV patients over 50 years. The survey collected non-confidential data patient profiles, diagnosis, demographics, current co-morbidities and rates of assessment annually in line with clinical guidelines provided insights into a number of factors that may be contributing to enhanced risk and poor management of HIV associated co-morbidities.

The advancement in combination antiretroviral therapy (ART) coupled with ongoing later life acquisition of HIV means that an increasing number of people living with HIV are falling into the ageing cohort of HIV positive individuals and while HIV management has traditionally focused on viral load control and treatment of HIV-related infections, HIV services are increasingly involved with management of age-related illnesses including diabetes kidney disease, cardiovascular disease, cancer, osteoporosis and cognitive impairment[1]

In the UK, over 101,200 people are living with and many of these patients fall in the over 50s age cohort. In 2016, more than a third (38%) of people accessing HIV care were aged 50 and above, compared with 17% in 2007[2].

Patients who are ageing with are increasingly experiencing many challenges relating to comorbidities as well as other social issues such as HIV stigma, discrimination, deprivation and social isolation.

Black Africans (BAs) living with HIV account for the large proportion of patients in the UK who are receiving HIV treatment. In 2015 there were over 27,000 black African people in the UK accessing HIV treatment; 65% of these were women and 35%; at least a third of who are over 50 and majority of who are living with at least one co-morbidity.

The BHIVA guidelines recommend that people attending HIV outpatient clinics should undergo regular screening in order to detect cardiovascular, renal, liver, bone and other comorbidities.[3] This includes lipid analysis [total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides] at baseline, yearly, and before and after treatment or targeted intervention, or more frequently if a high CHD risk dictates.

The EACS guidelines also recommend a similar approach for lipid measurements, but specifically suggest cardiovascular risk assessment at diagnosis, before and after ART, and annually for all men aged >40 years and women aged >50 years[4]

While many HIV patients aged over 50 access the NHS Health Checks; a national programme that screens for CVD, diabetes and renal disease for those aged 40–74 years as part of their primary care, there has not been clear evidence that the programme is addressing the concerns around the risk of co-morbidity or mortality among HIV patients in this age cohort. There have been concerns raised about the effectiveness and impact on health inequalities for this service.[5]

Furthermore, commissioning services historically have focused on HIV therapy alone without considering how comorbidity affects treatment outcome and total service costs. Research however shows that regular screening would identify those HIV-infected individuals most at risk of developing metabolic comorbidities meaning that appropriate interventions can be initiated to reduce modifiable risk factors.

In the UK, it is recommended that people living with HIV should have access to services to manage comorbidities safely and effectively either within the HIV service or in primary care and/or non-HIV specialist teams where appropriate.

The results of the AFYA survey however, demonstrates that not many current HIV services and care models are equipped to deal with the challenges faced by the ageing HIV-infected population, in terms of recognising and managing age-related issues, or indeed whether it falls to HIV services to meet this need at all[6]

Frustrations have also been raised about the lack of integration between specialist HIV services and general practice. Patients seeking treatment are often passed between multiple appointments with their HIV clinic and their GP, as there are restrictions on specialists prescribing medication for common HIV-related comorbidities such as statins.

The survey showed that older HIV patients from black and ethnic minority backgrounds are more susceptible diabetes kidney disease, cardiovascular disease, depression, among others and suffer significantly poorer quality of life outcomes. However, many are not being screened co-morbidities or effectively monitored for these conditions. The survey respondents highlighted range of issues including;

· The low perception of quality of life

· Lack of knowledge i.e. the onset of co-morbidities is viewed as being part and parcel of ageing by many black African patients.

· The imbalances in doctor patient relationships, lack of shared decision making

· Health systems i.e. poor knowledge around ART usage, co-prescribing and suboptimal two-way communication between HIV services and primary care[7]

· Poor ART adherence and problems with retention in care

· Isolation, depression, anxiety

· Financial stress, low disease and treatment literacy levels

· Cultural, language, faith barriers

Consideration of these issues by healthcare providers is necessary to optimising care and improving treatment outcomes for Black African who are living with HIV

The survey shows that there is an urgent need for review to ascertain how often Black Africans aged over 50 who are living with HIV in the UK are offered annual health assessments for co-morbidities including cardiovascular, diabetes, renal, mental health among others

The common emerging theme from the survey points to closer working with HIV consultants and clinicians such as audit leads within HIV clinics that have specialist ageing services as well as those with an interest in HIV and ageing to ensure that patients are effective assessed and supported in older age with HIV

[1] Campbell, L. Spectrum of chronic kidney disease in HIV-infected patients. HIV Med 2009; 10: 329–

336. Google Scholar, Crossref, Medline, ISI

[2] Public Health England (2017) ‘Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK’ [pdf]

[3] BHIVA Standards of Care for People Living with HIV 2018; 4 Comorbidities, Co-infections and Cancers;

Page 32

[4] Screening for Chronic Comorbid Diseases In People with HIV: The Need for a Strategic Approach;

DOI: 10.1111/j.1468-1293.2012.01055.x

[5] NHS Health Check: an innovative component of local adult health improvement and well-being

programmes in England; https://academic.oup.com/jpubhealth/article/37/2/177/1595202

[6] Specialist Care of Older Adults with HIV infection in the UK: A Service Evaluation;

[7] Wellesley R, Whittle A, Figueroa J et al. Does general practice deliver safe primary care to people living with HIV? A case-notes review. Br J Gen Pract 2015; 65: e655–e661

Africa Advocacy Foudation