HIV as a chronic disease: implications for long-term care at an AIDS-dedicated skilled nursing facility

Understanding the Relationship Between Nursing Home Experience With Human Immunodeficiency Virus and Patient Outcomes

BACKGROUND

As the population with human immunodeficiency virus (HIV) continues to age, the need for nursing home (NH) care is increasing.

OBJECTIVES

To assess whether NH's experience in treating HIV is related to outcomes.

RESEARCH DESIGN

We used claims and assessment data to identify individuals with and without HIV who were admitted to NHs in 9 high HIV prevalent states. We classified NHs into HIV experience categories and estimate the effects of NH HIV experience on patient's outcomes. We applied an instrumental variable using distances between each individual's residence and NHs with different HIV experience.

SUBJECTS

In all, 5,929,376 admissions for those without HIV and 53,476 admissions for residents with HIV.

MEASURES

Our primary outcomes were 30-day hospital readmissions, likelihood of becoming a long stay resident, and 180-day mortality posthospital discharge.

RESULTS

Residents with HIV tended to have poorer outcomes than residents without HIV, regardless of the NH they were admitted to. Residents with HIV admitted to high HIV experience NHs were more likely to be readmitted to the hospital than those admitted to NHs with lower HIV experience (19.6% in 0% HIV NHs, 18.7% in 05% HIV NHs and 22.9% in 5%-50% HIV NHs).

CONCLUSIONS

Residents with HIV experience worse outcomes in NHs than residents without HIV. Increased HIV experience was not related to improved outcomes.

Characteristics of older adults living with HIV accessing home and community care services in British Columbia, Canada

Over half of people living with HIV (PLHIV) engaged in care in British Columbia (BC) are age ≥50. The public home and community care (HCC) system offers formal support that PLHIV may turn to as they age, but little is known about access specific to PLHIV. Using data from the STOP HIV/AIDS cohort, which includes linked treatment and demographic records for PLHIV accessing care in BC, we compared older PLHIV (defined as those age ≥50) who did and did not access HCC services. We estimated adjusted odds ratios (aORs) for factors associated with HCC service utilization using logistic regression. This study included 5,603 PLHIV age ≥50, 837 (14.94%) of whom accessed any HCC service between 2005 and 2015. Services most commonly used were community nursing (8.98%, n = 503) and rehabilitation (7.73%, n = 433). Those who received HCC were more likely to be female (aOR = 1.56, 95% CI = 1.24, 1.98), have a history of injection drug use (aOR = 1.88, 95% CI = 1.57, 2.25), have a higher Charlson comorbidity score (aOR = 1.11, 95% CI:1.07, 1.15) and to have visited a general practitioner in the past year (aOR = 2.17, 95% CI = 1.77, 2.67). Approximately 15% of older PLHIV have accessed HCC, but the extent of potential unmet need for these services requires further research.

The Quality of Nursing Homes That Serve Patients With Human Immunodeficiency Virus

BACKGROUND/OBJECTIVES

As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long-term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes.

DESIGN

A cross-sectional comparative study.

SETTING

NHs in nine states, from 2001 to 2012.

PARTICIPANTS

A total of 46 918 NH-years accounting for 67 301 admissions by patients with HIV.

MEASUREMENTS

We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models.

RESULTS

After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P < .001), and a 0.4% percentage point higher 30-day rehospitalization rate (P < .01), compared to those with no HIV admissions. NHs with 5% to 50% of admissions with HIV had 7.0 more deficiencies (P < .001), a 0.1 lower star rating (P < .001), and a 1.5 percentage point higher rehospitalization rate (P < .001).

CONCLUSION

Persons with HIV were generally admitted to lower-quality NHs compared to persons without HIV. More efforts are needed to ensure that persons with HIV have access to high-quality NHs. J Am Geriatr Soc 67:2615-2621, 2019.

Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use

OBJECTIVES

Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status.

DESIGN

A cross-sectional comparative study.

SETTING

NHs in the 14 states accounting for 75% of persons living with HIV.

PARTICIPANTS

A total of 9 245 009 long-stay NH residents.

MEASUREMENTS

Using Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression.

RESULTS

Between 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9).

CONCLUSION

The prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.

Application of Community-Based Participatory Research Methods to a Study of Complementary Medicine Interventions at End of Life

Community-based participatory research (CBPR) principles can be successfully applied to the design and implementation of a complementary medicine study for adults with end-stage AIDS. The Yale Prevention Research Center partnered with Leeway, Inc., an AIDS-dedicated nursing facility, and other academic and clinical entities to conduct a randomized, controlled pilot trial of meditation and massage on quality of life at the end of life. Using CBPR principles, a methodology was developed that was scientifically rigorous, highly respectful, and acceptable to the 91% minority study population. Using continuous, open communication among all involved parties, challenges were satisfactorily addressed in a timely manner. Fifty-eight residents (97% of those eligible) with end-stage AIDS participated from November 2001 to September 2003. Subjects received 1-month interventions of meditation, massage, combined meditation and massage, or standard care. The study of quality-of-life in end-stage AIDS poses unique challenges well met by applying CBPR principles to an academic-community research partnership.

Trends in hospital deaths among human immunodeficiency virus-infected patients during the antiretroviral therapy era, 1995 to 2011

OBJECTIVE

Mortality in hospitalized human immunodeficiency virus (HIV)-infected patients is not well described. We sought to characterize in-hospital deaths among HIV-infected patients in the antiretroviral (ART) era and identify factors associated with mortality.

METHODS

We reviewed the medical records of hospitalized HIV-infected patients who died from January 1, 1995 to December 31, 2011 at an urban teaching hospital. We evaluated trends in early and late ART use and deaths due to acquired immunodeficiency syndrome (AIDS) and non-AIDS, and identified clinical and demographic correlates of non-AIDS deaths.

RESULTS

In-hospital deaths declined significantly from 1995 to 2011 (P < 0.0001); those attributable to non-AIDS increased (43% to 70.5%, P < 0.0001). Non-AIDS deaths were most commonly caused by non-AIDS infection (20.3%), cardiovascular (11.3%) and liver disease (8.5%), and non-AIDS malignancy (7.8%). Patients with non-AIDS compared to AIDS-related deaths were older (median age 48 vs 40 years, P < 0.0001), more likely to be on ART (74.1% vs 55.8%, P = 0.0001), less likely to have a CD4 count of <200 cells/mm(3) (47.2% vs 97.1%, P < 0.0001), and more likely to have an HIV viral load of ≤400 copies/mL (38.1% vs 4.1%, P < 0.0001). Non-AIDS deaths were associated with 4.5 and 4.2 times greater likelihood of comorbid underlying liver and cardiovascular disease, respectively.

CONCLUSIONS

Non-AIDS deaths increased significantly during the ART era and are now the most common cause of in-hospital deaths; non-AIDS infection, cardiovascular and liver disease, and malignancies were major contributors to mortality. Higher CD4 cell count, liver, and cardiovascular comorbidities were most strongly associated with non-AIDS deaths. Interventions targeting non-AIDS-associated conditions are needed to reduce inpatient mortality among HIV-infected patients.

Storylines of aging with HIV: shifts toward sense making

Aging with HIV is a new phenomenon. It is expected that by 2015, approximately half of adults living with HIV in the United States will be age 50 and older. We used narrative inquiry to explore how older adults with HIV storied their experience and made sense of aging. Over a 3.5-year period, we interviewed 5 older adults living with HIV for 13 to 24 years. In analyzing the coconstructed stories, we identify six storylines that enhance understanding and guide listening: embodiment of the illness, sense making, death and loss, secrets and stigma, identity, and seeking connection. We theorize that the degree to which one reconciles each storyline influences how well one lives with illness. We share a storied exemplar to illustrate these storylines in one participant's experience of aging with HIV. These findings emphasize how vital is telling one's illness story, because sense making happens in the telling.

Complex care needs of patients with late-stage HIV disease: a retrospective study

This retrospective chart review provides a profile of an emerging population of vulnerable HIV patients with complex comorbidities. Data were abstracted from all 83 patients admitted in 2008 to Casey House, a community-based hospital dedicated to supportive and palliative care for persons with HIV in Toronto, Canada. We describe patient characteristics, including medical and psychiatric conditions, and use a Venn diagram and case study to illustrate the frequency and reality of co-occurring conditions that contribute to the complexity of patients' health and health care needs. The mean age at admission was 49.2 years (SD = 10.5). Sixty-seven patients (80.7%) were male. Patients experienced a mean of 5.9 medical comorbidities (SD = 2.3) and 1.9 psychiatric disorders (lifetime Axis I diagnoses). Forty patients (48.2%) experienced cognitive impairment including HIV-associated dementia. Patients were on a mean of 11.5 (SD = 5.3) medications at admission; 74.7% were on antiretroviral medications with 55.0% reporting full adherence. Current alcohol and drug use was common with 50.6% reporting active use at admission. Our Venn diagram illustrates the breadth of complexity in the clients with 8.4% of clients living in unstable housing with three or more medical comorbidities and two or more psychiatric diagnoses. Comprehensive HIV program planning should include interventions that can flexibly adapt to meet the multidimensional and complex needs of this segment of patients. Researchers, policy-makers, and clinicians need to have greater awareness of overlapping medical, psychiatric and psychosocial comorbidities. Inclusion of the needs of these most vulnerable patients in the development of evidence-based guidelines is an important step for effectively treating, preventing, and planning for the future of HIV/AIDS care.

Does social isolation predict hospitalization and mortality among HIV+ and uninfected older veterans?

OBJECTIVES

To compare levels of social isolation in aging veterans with and without the human immunodeficiency virus (HIV) and determine associations with hospital admission and mortality.

DESIGN

Longitudinal data analysis.

SETTING

The Veterans Aging Cohort Study (VACS), at eight VA Medical Centers nationally.

PARTICIPANTS

Veterans aged 55 and older enrolled in VACS from 2002 to 2008 (N = 1,836).

MEASUREMENTS

A Social Isolation Score (SIS) was created using baseline survey responses about relationship status; number of friends and family and frequency of visits; and involvement in volunteer work, religious or self-help groups, and other community activities. Scores were compared according to age and HIV status, and multivariable regression was used to assess effects of SIS on hospital admission and all-cause mortality.

RESULTS

Mean SIS was higher for HIV-positive (HIV+) individuals, with increasing difference according to age (P = .01 for trend). Social isolation was also more prevalent for HIV+ (59%) than uninfected participants (51%, P < .001). In multivariable regression analysis of HIV+ and uninfected groups combined, adjusted for demographic and clinical features, isolation was independently associated with greater risk of incident hospitalization (hazard rate (HR) = 1.25, 95% confidence interval (CI) = 1.09-1.42) and risk of all-cause mortality (HR=1.28, 95% CI = 1.06-1.54). Risk estimates calculated for HIV+ and uninfected groups separately were not significantly different.

CONCLUSION

Social isolation is associated with greater risk of hospitalization and death in HIV+ and uninfected older veterans. Despite similar effects in both groups, the population-level effect of social isolation may be greater in those who are HIV+ because of the higher prevalence of social isolation, particularly in the oldest individuals.

Preliminary report of the integration of a palliative care team into an intensive care unit

Nearly half of Americans who die in hospitals spend time in the intensive care unit (ICU) in the last 3 days of life. Minority patients who die in the ICU are less likely to formalize advance directives and surviving family members report lower satisfaction with the provision of information and sensitivity to their cultural traditions at the end-of-life. This is a descriptive report of a convenience sample of 157 consecutive patients served by a palliative care team which was integrated into the operations of an ICU at Montefiore Medical Center in the Bronx, New York, from August 2005 until August 2007. The team included an advance practice nurse (APN) and social worker. A separate case-control study was conducted comparing the length of hospital stay for persons who died in the ICU during the final 6 months of the project, prior to and post-palliative care consultation for 22 patients at the hospital campus where the project team was located versus 24 patients at the other campus. Pharmaco-economic data were evaluated for 22 persons who died with and 43 who died without a palliative care consultation at the intervention campus ICU to evaluate whether the project intervention was associated with an increase in the use of pain medications or alterations in the use of potentially non-beneficial life-prolonging treatments in persons dying in the ICU. Data was abstracted from the medical record with a standardized chart abstraction instrument by an unblinded research assistant. Interviews were conducted with a sample of family members and ICU nurses rating the quality of end-of-life care in the ICU with the Quality of Dying and Death in the ICU instrument (ICUQODD), and a family focus group was also conducted. Forty percent of patients were Caucasian, 35% were African American or Afro-Caribbean, 22% Hispanic and 3% were Asian or other. Exploration of the patients' and families' needs identified significant spiritual needs in 62.4% of cases. Education on the death process was provided to 85% of families by the project team. Twenty-nine percent of patients were disconnected from mechanical ventilators following consultation with the Palliative Care Service (PCS), 15.9% of patients discontinued the use of inotropic support, 15.3% stopped artificial nutrition, 6.4% stopped dialysis and 2.5% discontinued artificial hydration. Recommendations on pain management were made for 51% of the project's patients and symptom management for 52% of patients. The project was associated with an increase in the rate of the formalization of advance directives. Thirty-three percent of the patients who received PCS consultations had 'do not resuscitate' orders in place prior to consultation and 83.4% had 'do not resuscitate' orders after the intervention. The project team referred 80 (51%) of the project patients to hospice and 55 (35%) patients were enrolled on hospice, primarily at the medical center. The mean time from admission to palliative care consultation at the project site was 2.8 days versus 15.5 days at the other campus (p = 0.0184). Median survival times from admission to the medical center were not significantly different when stratified by palliative care consultation status: 12 days for the control group (95% CI 8-18) and 13.5 days for the intervention group (95% CI 8-20). Median charges for the use of opioid medications were higher (p = 0.01) for the intervention group but lower for use of laboratory (p = 0.004) and radiology tests (p = 0.027). We conclude that the integration of palliative care experts into the operation of critical care units is of benefit to patients, families and critical care clinicians. Preliminary evidence suggest that such models may be associated with improved quality of life, higher rates of formalization of advance directives and utilization of hospices, as well as lower use of certain non-beneficial life-prolonging treatments for critically ill patients who are at the end of life.

Preliminary Report of a Pilot Tele-Health Palliative Care and Bioethics Program for Residents in Skilled Nursing Facilities

Currently about 25% of Americans die in nursing homes, many with poorly controlled pain and other symptoms, with minimal provisions for psychosocial support. New models are necessary to lessen structural and process barriers to give effective end-of-life care in nursing homes.

Objectives

1) To extend hospital-based Bioethics Consultation Services (BCS) and Palliative Care Services (PCS) at Montefiore Medical Center (MMC) in the Bronx to two local Skilled Nursing Facilities (SNFs), Morningside House Aging in America (MSH) using direct face-to-face consultations and Beth Abraham Health Systems (BAHS) via video consultations (VC); 2) Achieve improvements in quality of life and comfort for elderly residents and their families; 2a) Improve the level of practice and increase staff satisfaction with palliative care content-related knowledge and bioethical analysis.

Methods

We report preliminary findings of this two group quasi experimental project with results of pre- and post-tests rating content-related knowledge in aspects of end-of-life care for staff. Select pre-test and post-test questions were given to physicians and other staff, but were re-configured for, registered and licensed practice nurses, social workers, and certified nursing assistants from the End-of-Life Physician Education Resource Center (EPERC). Patient, family, and staff ratings of the quality of palliative care were measured with a Palliative Outcomes Scale (POS) one week prior to and post consultation.

Results

72 staff attended in-services; 53 completed pre-tests and 49 post-tests. Overall knowledge scores increased for 9 of the 16 items that were analyzed. There were improvements in knowledge scores in 12 of 16 items tested for staff content related knowledge which were statistically significant in regard to management of cancer pain from 63.8% to 81.5% (p = 0.03) and a trend to significance for assessment and management of delirium from 31.6% to 61.9% (p = 0.073). Seventy five POS surveys were completed from 13 video-conferenced Palliative Care consultations and 14 direct face-to-face consultations from March 2008 to January 2009. There were improvements in ratings for some aspects of quality of care on the POS. Patient and staff aggregate response scores for the POS were significantly improved between baseline and follow-up (Wilcoxon signed-rank test p = 0.0143 and p = 0.005) at the videoconsultation site and for family and staff at the face-to-face consultation site (Wilcoxon signed-rank test p = 0.0016 and p = 0.0012).

Conclusion

Preliminary evidence suggests that use of real time videoconferencing to connect hospital-based Bioethics and Palliative Care clinicians with patients, families, and staff in Skilled Nursing Facilities may enhance some aspects of end-of-life care for their residents, as well as content related knowledge in core aspects of end-of-life care for interdisciplinary groups of staff or caregivers.

Community outreach to patients with AIDS at the end of life in the inner city: reflections from the trenches

Indigenous community health outreach workers (CHWs), who serve as a bridge between underserved, difficult-to-reach minority populations and health professionals, can play a critical role in bringing palliative care to patients dying of AIDS and other illnesses in the inner city. Although the contribution of CHWs in the delivery of "curative" and preventive services has been well established, little attention has been given to CHWs in palliative care. Integrating the medical literature with experiences of a team providing HIV palliative care in the Bronx, a descriptive typology of critical stages and components in the work of CHWs in end-of-life care in the inner city is presented. A longitudinal case narrative, told from the perspective of the CHW, is used to demonstrate the richness and complexity of the CHW's role. The article concludes with a description of the experience of the CHW, straddling two worlds--the world of the inner city patient and the world of the health care providers--and explores the special characteristics of the individuals who can fill this vital role in palliative care.

Predictors of mortality for patients with advanced disease in an HIV palliative care program

BACKGROUND

Despite advances in treatment, AIDS and its associated comorbidities remain important causes of death. Traditional HIV prognostic markers may be less useful in predicting death in current late-stage patients than in the era before highly active antiretroviral therapy.

METHODS

We used standardized baseline and follow-up data to describe causes of death and predictors of mortality in a cohort of patients with advanced disease referred to a specialized HIV palliative care program at a large urban medical center.

RESULTS

Of 230 patients, 56% were male with a median age of 43 years; 54% were Hispanic and 39% were African American; 41% had a history of injection drug use; 89% had prior AIDS-defining illnesses; and median baseline values included a CD4 count of 39 cells/mm, HIV viral load of 65,202 copies/mL, Karnofsky score of 30, and 5 impaired activities of daily living (ADL). Over a median follow-up of 126 days (range: 1-823 days), 120 patients died; 54% of these died of late-stage HIV disease and/or bacterial pneumonia or sepsis, 19% of non-AIDS-defining cancers, 13% of liver failure and/or cirrhosis, and 12% of other progressive end-organ disease (eg, cardiac, pulmonary, renal). On multivariate analysis, death was predicted only by age (>65 years), baseline number of ADL impairments, and Karnofsky score (P < 0.0001 for all) and not by any AIDS-specific variables.

CONCLUSIONS

For patients with late-stage disease referred to an HIV palliative care program, age and markers of functional status were more predictive of mortality than traditional HIV prognostic variables. Close to half of all deaths were attributable to non-AIDS-specific causes, including cancer and end-organ failure. These findings suggest the need for renewed study of predictors of mortality and prognostic markers in patients with advanced HIV disease and related comorbidities in the HAART era.

A Randomized Controlled Trial of Meditation and Massage Effects on Quality of Life in People with Late-Stage Disease: A Pilot Study

CONTEXT

Certain meditation practices may effectively address spiritual needs near end-of-life, an often overlooked aspect of quality of life (QOL). Among people subject to physical isolation, meditation benefits may be blunted unless physical contact is also addressed.

OBJECTIVE

To evaluate independent and interactive effects of Metta meditation and massage on QOL in people with acquired immunodeficiency syndrome (AIDS).

DESIGN

Randomized controlled blinded factorial pilot trial conducted from November 2001 to September 2003.

SETTING

An AIDS-dedicated skilled nursing facility in New Haven, Connecticut.

PARTICIPANTS

Fifty-eight residents (43% women) with late stage disease (AIDS or comorbidity).

INTERVENTIONS

Residents were randomized to 1 month of meditation, massage, combined meditation and massage, or standard care. The meditation group received instruction, then self-administered a meditation audiocassette daily. A certified massage therapist provided the massage intervention 30 minutes per day 5 days per week.

OUTCOME MEASURE

Changes on Missoula-Vitas QOL Index overall and transcendent (spiritual) scores at 8 weeks.

RESULTS

The combined group showed improvement in overall (p = 0.005) and transcendent (p = 0.01) scores from baseline to 8 weeks, a change significantly greater (p < 0.05) than the meditation, massage, and control groups.

CONCLUSIONS

The combination of meditation and massage has a significantly favorable influence on overall and spiritual QOL in late-stage disease relative to standard care, or either intervention component alone.

Rehabilitation in HIV/AIDS: development of an expanded conceptual framework

In industrialized countries where HIV infection is becoming a chronic, episodic condition, rehabilitation services have the potential to play an expanded role for people living with HIV/AIDS (PLHAs). However, little is known about rehabilitation in the context of HIV. This paper documents the development of an enhanced, multidisciplinary conceptual framework of rehabilitation in the context of HIV, using the perceptions of PLHAs and rehabilitation professionals. Rehabilitation, broadly defined, is a dynamic process that includes all prevention and/or treatment activities and/or services that address body impairments, activity limitations and participation restrictions for an individual. The framework was developed through broad consultation and interviews with thirteen key informants. Themes that emerged from analysis of interviews related to concepts of rehabilitation in the context of HIV, rehabilitation professionals' roles in the context of HIV, and barriers to access and delivery of rehabilitation services. While there was some variation, key informants generally viewed rehabilitation as a goal-oriented and client-centered process with the potential to impact a range of life domains. Themes were presented to members of a national advisory committee (including PLHAs and health care providers), who produced the foundation of the HIV rehabilitation framework. The framework uses the perspective of the person living with HIV/AIDS, and includes individual life domains that may be affected by HIV, drawing and expanding upon the World Health Organization's (WHO's) International Classification of Functioning, Disability and Health.

Does palliative care improve outcomes for patients with HIV/AIDS? A systematic review of the evidence

BACKGROUND

The need for palliative care in HIV management is underlined by the high prevalence of pain and symptoms, the toxicity, side effects, and virological failure associated with antiretroviral therapy, emergence of co-morbidities, continued high incidence of malignancies, late presentation of people with HIV disease, and the comparatively higher death rates among the infected individuals.

METHODS

A systematic review was undertaken to appraise the effect of models of palliative care on patient outcomes. A detailed search strategy was devised and biomedical databases searched using specific terms relevant to models of palliative care. Data from papers that met the inclusion criteria were extracted into common tables, and evidence independently graded using well described hierarchy of evidence.

RESULTS

34 services met the inclusion criteria. Of these, 22 had been evaluated, and the evidence was graded as follows: grade 1 (n = 1); grade 2 (n = 2); grade 3 (n = 7); grade 4 (n = 1); qualitative (n = 6). Services were grouped as: home based care (n = 15); home palliative care/hospice at home (n = 7); hospice inpatient (n = 4); hospital inpatient palliative care (n = 4); specialist AIDS inpatient unit (n = 2); and hospital inpatient and outpatient care (n = 2). The evidence largely demonstrated that home palliative care and inpatient hospice care significantly improved patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing.

CONCLUSIONS

Although the appraisal of evidence found improvements across domains, the current body of evidence suffers from a lack of (quasi) experimental methods and standardised measures. The specialism of palliative care is responding to the clinical evidence that integration into earlier disease stages is necessary. Further studies are needed to both identify feasible methods and evaluate the apparent beneficial effect of palliative care on patient outcomes in the post-HAART era.

Treatment of HIV/AIDS in the Nursing Home: Variations in Rural and Urban Long-term Care Settings

OBJECTIVES

With the increased use of antiretroviral therapy, more patients with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) are surviving for long periods of time. The aim of this study was to determine the availability of specialty HIV/AIDS services in long-term care facilities, and to determine differences in the availability of these services between rural and urban nursing homes.

METHODS

1,423 nursing homes from the 1999 National Nursing Home Survey were stratified by rural/urban status and compared using chi2 analysis and logistic regression.

RESULTS

Less than 1% of surveyed nursing homes in the United States provided specialty HIV/AIDS services. While there was evidence that larger nursing homes are more likely to provide HIV/AIDS-related services, there were no significant differences between rural and urban nursing homes in the provision of specialty HIV/AIDS services.

CONCLUSIONS

A vast majority of nursing homes in the United States do not provide any specialty areas for HIV/AIDS care. As our population ages and the life span of those diagnosed with HIV/AIDS continues to increase, nursing homes will begin to see patients diagnosed with HIV/ AIDS among those seeking care.

Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy

In contrast to the first decade of the AIDS epidemic, the past decade has seen an increasing separation between AIDS care and palliative care services. While this may be due in part to the perception that AIDS is no longer a uniformly fatal illness, AIDS in fact remains an important cause of morbidity and mortality for young adult populations in the United States, particularly among certain racial-ethnic minorities. Death rates have remained steady since the dramatic decreases noted in the mid-1990s, and causes of death now increasingly include co-morbidities such as hepatitis B, C, end-organ failure, and various malignancies. Moreover, as AIDS has been transformed into a more manageable, chronic disease in the era of 'highly active antiretroviral therapy' (HAART), the opportunities for palliative care interventions have only increased. Patients with AIDS continue to experience a high burden of pain and other chronic symptoms, over a longer period of time, with a disease course marked by more cumulative exacerbations and remissions than when AIDS was a stereotypic, rapidly fatal illness. Advance care planning and discussions of goals of care are more complex and involve more uncertainty than was the case when prognosis was clear-cut and treatment options were more limited. For all of these reasons, it is important for the distance which has developed between HIV and palliative care providers to be bridged. Contrary to popular perceptions, palliative medicine continues to have much to offer in the HAART era for the care of patients and families with HIV/AIDS, for whom treatment outcomes will only benefit from greater integration of disease-specific and palliative interventions. The challenge for care providers is now to implement successful strategies for integrating AIDS and palliative care services in all relevant clinical environments.

Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes

BACKGROUND

Despite major advances in therapy, acquired immune deficiency syndrome (AIDS) remains an important cause of morbidity and mortality in young adult populations. As AIDS has been converted into a chronic disease, it has resulted for some patients in a more protracted course of symptomatic illness. Comprehensive care for late-stage human immunodeficiency virus (HIV) disease now involves an increasingly complex mixture of disease-specific and palliative therapies, requiring coordination and collaboration between AIDS and palliative care services. We describe the experience of developing a palliative care consultation service for patients with AIDS at a large urban teaching hospital, funded by the Health Resources and Services Administration as one of six national demonstration projects for the integration of HIV and palliative care.

SETTING

An 1100-bed medical center in the Bronx, New York. The multidisciplinary consultation team included a physician, nurse practitioner, social worker, chaplain, outreach worker, psychiatrist, and ethicist. Patients were referred from inpatient AIDS services and outpatient care sites.

METHODS

Patients underwent standardized assessment with clinical case review, Memorial Symptom Assessment Scale (MSAS), Mini-Mental Status Examination (MMSE), Karnofsky score, and Rapid Disability Rating Scale (RDRS). Interventions and follow-up outcomes were recorded and categorized. All deaths were analyzed and predictors of mortality were determined by bivariate and logistic regression analysis.

RESULTS

Program referrals have been steady, with 132 patients followed by the consultation service from July 2000 through October 2001; 73% were referred from inpatient services (representing 12% of all AIDS inpatients admitted to the hospital during the study period); 57% of patients were male, 36% African American, 55% Hispanic; 44% had a history of injection drug use. Median baseline values included: CD4+ T-lymphocyte count = 35/mm3, HIV viral load = 53,813 copies per milliliter, Karnofsky = 40, MMSE = 0 (with a median score of 24 for those able to complete the examination); number of severe symptoms reported by MSAS = 4; 71% had one or more serious impairments in activities of daily living (ADL) by RDRS. In addition to AIDS, 20% of patients had malignancies and 13% had end-stage liver disease. Presenting problems and priority issues identified at consultation included: care decisions/goals of care (68%), pain (40%), psychosocial issues (31%), depression (23%), anxiety (19%), nausea/vomiting (14%), insomnia (13%), and patient/family/team conflict (13%); these problems were fully or partially resolved in 68-91% of cases. 63 patients died (median days enrolled = 35); leading causes of death included AIDS (38%), sepsis (19%), cancer (19%), and liver failure/cirrhosis (17%). Death was predicted only by baseline functional status (Karnofsky, MMSE, ADL impairment), and not by CD4+ count, viral load, or any AIDS-specific variables.

CONCLUSION

Results suggest an important and ongoing need for palliative care services for patients with advanced HIV/AIDS, whose needs are likely to increase as AIDS evolves into more of a chronic disease. Patients were readily referred from predominantly inpatient settings, with very advanced disease; problems included a mix of medical and psychosocial issues, and were readily resolved by the consultation team in most cases. Death was predicted only by baseline functional status, not by traditional HIV disease markers. Mortality reflected both AIDS-related and non-AIDS-specific causes. Further studies are needed to identify more specific prognostic variables and to continue to improve palliative care treatment outcomes in late-stage patients with AIDS.

The physiologic health care needs of HIV-infected black men on admission to an AIDS-dedicated nursing home

The purpose of this study is to describe the physiologic health care needs of HIV-infected Black men on admission to an AIDS-dedicated nursing home. Participants were 68 Black men aged 26 to 60 years who were admitted to an AIDS-dedicated nursing home in the southern New England area between 1995 and 1999. The participants were very ill and weak on their admission to the nursing home, with most having diagnoses of AIDS (n = 65), an average Karnofsky Performance Scale score of 44 (SD = 14.90), and some degree of mental impairment. The late-stage of disease of the participants was reflected in their multiple symptomatology and functional impairment in activities of daily living. With patients living longer in the chronic disease stages of HIV disease, the results of this study provide support for the further investigation of the most effective long-term care settings for Black men with HIV/AIDS. The results also have implications for the multiple clinical roles nursing can assume within HIV/AIDS long-term care settings.

The prevalence of pain in pediatric human immunodeficiency virus/acquired immunodeficiency syndrome as reported by participants in the Pediatric Late Outcomes Study (PACTG 219)

OBJECTIVES

As the life expectancy of children with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) increases, quality-of-life outcomes are of increasing concern. The prevalence of pain in adults with AIDS ranges from 40% to 60%, depending on stage of illness. There is limited research concerning pain in HIV-infected children and youth.

DESIGN

The General Health Assessment for Children was administered to caregivers of HIV-infected children and youth enrolled in the Pediatric Late Outcomes Study (PACTG 219), a prospective cohort study. Pain is assessed over the previous month with 7 questions. For the purpose of this analysis, we defined pain as the presence of pain of at least moderate intensity. Participants were observed from January 1, 1996, to December 31, 1999.

RESULTS

A total of 985 HIV-positive participants had a baseline pain evaluation in 1995. The prevalence of pain remained relatively constant during each year of observation, averaging 20%. Lower CD4+ T-lymphocyte percentage, female gender, and an HIV/AIDS-related diagnosis were highly associated with an increased risk of reported pain. Pain was also independently associated with increased risk of death. After adjusting for CD4 percentage, use of combination therapy including protease inhibitors, comorbid diagnoses, and other sociodemographic characteristics, individuals reporting pain were over 5 times more likely to die than those not reporting pain (hazard ratio = 5.07; 95% confidence interval = 3.23-7.95).

CONCLUSIONS

Pain is a frequently encountered symptom in children and youth with HIV disease and is also associated with increased mortality. These findings emphasize the importance of pain management in this population.

Quality of care measurement in nursing home AIDS care: a pilot study

A pilot study was conducted to identify which, if any, demographic or quality indicators differentiate HIV-positive patients from other long-term care patients. This study used the Minimum Data Set files for all New York state nursing homes submitted in 1997. Chi-square tests were used to assess difference in proportions of demographics and quality indicators between HIV-positive and HIV-negative patients. The HIV-positive patients tended to be between 40 and 59 years of age and male and were more likely to be Black or Hispanic. HIV-positive patients had a significantly higher prevalence of diagnosis or symptoms of depression without any treatment compared to HIV-negative patients. HIV-positive patients had significantly higher prevalence of weight loss, antipsychotic use, antianxiety/hypnotic use, and incontinence of bladder and bowel compared to HIV-negative patients. This study paves the way for the development of a more appropriate quality indicator system tailored to the AIDS population and allows facilities to make necessary improvements in the quality of care offered to this vulnerable population.

General medical and psychiatric comorbidity among HIV-infected veterans in the post-HAART era

We examined the prevalence of HIV, general medical, and psychiatric comorbidities by age based on a recent multisite cohort of HIV infected veterans receiving care: the Veterans with HIV/AIDS 3 Site Study (VACS 3). VACS 3 includes 881 adult patients with HIV infection enrolled between June 1999 and July 2000. Providers reported their patients' CDC-defined HIV comorbidities, general medical comorbidities (based on Duke and Charlson comorbidity scales), and psychiatric comorbidity. Mean age of participants was 49 years and 54% were African-American. The most common HIV comorbidities were oral candidiasis (21%), peripheral neuropathy (16%), and herpes zoster (16%). The most common general medical comorbidities included chemical hepatitis (53%), hypertension (24%), and hyperlipidemia (17%). The mean number of HIV and general medical comorbidities experienced by patients were respectively 1.1 and 1.4 (P < .001). Older (> or = 50 years) HIV-infected patients experienced a greater number of general medical comorbidities than those < 50 years (respectively 1.7 versus 1.2, P < .001). There was no significant difference in mean HIV comorbidity number by age. Based on patient report, 46% had significant depressive symptoms (> or = 10 on 10-item CES-D) and 21% reported at-risk drinking (> or = 8 on AUDIT). Providers reported 32% of patients had anxiety, 4% mania, 4% schizophrenia, and 11% cognitive impairment/dementia. General medical and psychiatric comorbidities constituted a higher disease burden for HIV-infected veterans than HIV comorbidities. Whether these comorbidities are due to antiretroviral drug toxicity or are age or lifestyle-associated conditions, the substantial prevalence of these "non-HIV" comorbidities suggest an important role for general medical and psychiatric management of HIV-infected patients.