Aging with HIV: Seeking a Suitable Model of Care

When Eugenia L. Siegler, MD, pursued her residency in internal medicine at Bellevue Hospital in the 1980s, she cared for a number of patients with HIV. “After that I went on to specialize in geriatrics and over the years, I may have encountered a patient or two with HIV, but I was not focused on HIV care,” says Dr. Siegler, Medical Director of Geriatrics Inpatient Services, Division of Geriatrics and Palliative Medicine at NewYork-Presbyterian/Weill Cornell Medical Center.

That was until Susan Ball, MD, Assistant Director of the Glenn Bernbaum Unit, Center for Special Studies at Weill Cornell, presented at a geriatric grand rounds on the increasing number of older adults who are living with HIV/AIDS. According to the Centers for Disease Control and Prevention, in 2015 an estimated 47 percent of Americans living with diagnosed HIV were age 50 and older. As of June 2017, 23 percent of people living with HIV in New York City were 60 or older, and that percentage is increasing. Although this aging demographic represents a remarkable achievement in HIV care, older people living with HIV are at higher risk than their uninfected counterparts for multimorbidity, cognitive impairment, poly-pharmacy, depression, loneliness, frailty, and other medical and social problems.

“What is clear is that HIV care must be global and inclusive, embracing geriatric and palliative care so that older people can take advantage of the many years that successful antiretroviral therapy has enabled them to live.”

— Dr. Eugenia L. Siegler

“Dr. Ball’s talk shocked me. These individuals have seen accentuated aging with more comorbidities at a younger than expected age, as well as a heavier burden of psychiatric illness. Their social networks are fragile and often unable to provide adequate support. It got me thinking that we needed to do something,” says Dr. Siegler, who with funding from the Fan Fox and Leslie R. Samuels Foundation, began collaborating with the Center for Special Studies (CSS), one of the first programs in New York to be recognized as a Designated AIDS Center by the Department of Health.

Initially, Dr. Siegler and Weill Cornell colleague Harjot K. Singh, MD, along with collaborators from ACRIA, a community-based HIV research and education organization, arranged focus groups of patients and providers at CSS to determine the needs of older adults with HIV/AIDS and how the involvement of geriatrics might be helpful.

“One thing that became clear was that patients wanted to stay with their primary care physicians, many of whom have been with them for 20 years,” says Dr. Siegler. “And their physicians did not want to give up their patients, either. For many patients, HIV is no longer their main problem. They live with HIV, but it is all of their other medical issues — heart, kidney, and lung disease — that are the reasons for their medical care.” Colleagues Megan Shen, PhD, and Assistant Research Coordinator Chelsie Burchett are continuing to analyze the focus group data to help determine what kind of programming would best meet the needs of people aging with HIV.

Dr. Siegler and Weill Cornell geriatrician Tessa M. del Carmen, MD, who is especially interested in the palliative needs of people with HIV, now serve as on-site geriatric consultants at the CSS, as well as provide education to staff and providers on aging. “HIV is a treatable, chronic illness, but it’s not invisible. Even when the virus is undetectable, it affects the body in subtle but important ways,” says Dr. Siegler. “There is a broad range of presentations among the older population with HIV. Some people who nearly died have survived, but their bodies have suffered the consequences of this infection and its treatment. There are others whose HIV has not had as marked an impact physiologically, but nevertheless, they still live with it and they still have to think about it. And now they are also dealing with the problems related to aging.”

“Medical care is just one small part of what is important to these individuals as they age,” adds Dr. Siegler. “There is still stigma attached to having HIV. Even as medications become very effective and people are living long and healthy lives, many are still afraid to disclose their illness. Social isolation is also one of the problems we see, so we have added a social component to our program.”

Dr. Siegler continues to collaborate with ACRIA in their current study of the psychosocial impact of aging with HIV, ROAH 2.0 (Research on Aging with HIV), and with Marshall Glesby, MD, PhD, from the Division of Infectious Diseases, the Principal Investigator of a study examining the impact of psychosocial and clinical variables on frailty and markers of inflammation.

Developing a Model of Integrated Care

Dr. Siegler and her colleagues recently presented varying views surrounding the delivery of care for this older, diverse population in an article published in the October 2018 issue of the Journal of the International AIDS Society.

“Providers are examining different ways to incorporate geriatric assessment into their clinical programs,” says Dr. Siegler. “What we in the field are trying to figure out is how the geriatric world and the HIV world intersect. Models of care for the elderly have been tested, but it’s not clear that a person who is 60 with HIV is going to need the same set of services or care that’s constructed for a woman in her 80s. Do you just combine the aging services network and the HIV services network and have people use what they need from each, or do you ask for programs to develop HIV-specific services or programs that modify the mix? What is clear is that HIV care must be global and inclusive, embracing geriatric and palliative care so that older people can take advantage of the many years that successful antiretroviral therapy has enabled them to live.”

Dr. Siegler notes that many providers who specialized in HIV care are finding that they are doing more primary care today. “It may be that in the next 10 or 20 years, primary care physicians and geriatricians will manage the primary care, and the HIV specialists will manage the medications. There are many aspects of care that are quite complex, such as coinfections with hepatitis C and complicated sexually transmitted infections that are beyond the reach of those of us in primary care, so we need infectious disease specialists to call on,” adds Dr. Siegler. “It will have to be settled out, but I think there will be opportunities for a variety of practice models in the future.”

Reference Article
Siegler EL, Burchett CO, Glesby MJ. Older people with HIV are an essential part of the continuum of HIV care. Journal of the International AIDS Society. 2018 Oct;21(10):e25188.

For More Information
Dr. Eugenia L. Siegler | [email protected]