HIV disease in primary care

Patients' perspectives on the development of HIV services to accommodate ageing with HIV: a qualitative study

The objective of this study was to identify the aspects of healthcare that are most valued by people with HIV and to describe their concerns and preferences for the future delivery of services for non-HIV-related illness. Twelve focus groups of people receiving HIV care were conducted in community settings in South-East England. Groups were quota sampled based on age, gender, sexual orientation and ethnicity. Data were analysed using Framework Analysis. The results showed that among the 74 respondents (61% male), a preference for maintaining all care within specialist HIV clinics was commonplace, but was highest among participants with more extensive histories of HIV and comorbidities. Participants valued care-coordination, inter-service communication and timely updates to medical notes. There were high levels of concern around HIV skills in general practices and the capacity of general practitioners to manage patient confidentiality or deal appropriately with the emotional and social challenges of living with HIV. Participants valued, and had an overall preference for, the specialist knowledge and skills of HIV services, suggesting that non-HIV-specialist services will need to build their appeal if they are to have a greater future role in the care of people with HIV. Particular concerns that should be addressed include: patient confidence in the HIV knowledge and skills of non-specialist service providers; clear processes for prescribing and referrals; improved levels of care-coordination and communication between services and increased patient confidence in the capacity of primary care to maintain confidentiality and to appreciate the stigma associated with HIV.

Pneumonia and influenza hospitalization in HIV-positive seniors

HIV-positive persons and the elderly have increased risk for influenza-related complications, including pneumonia. Using claims data for pneumonia and influenza (P&I) hospitalization in the USA, we described the temporo-demographic trends and in-patient case-fatality in persons aged ≥ 65 years by HIV status. Our results showed a near doubling in the fraction of P&I admissions representing HIV-positive persons between 1991 and 2004 [relative risk (RR) 1·95, 95% confidence interval (CI) 1·80-2·13]. HIV-positive adults were younger (70·3 vs. 79·9 years, P<0·001), and had higher case-fatality (18·0% vs. 12·6%, P<0·001). Adjusting for other variables, case-fatality decreased by 5·8% in HIV-positive persons with the availability of highly active antiretroviral therapy (P=0·032). However, HIV-positive seniors were still 51% more likely to die during hospitalization than HIV-negative persons in 2004 (OR 1·51, 95% CI 1·23-1·85). HIV-infected persons represent a growing fraction of the elderly population hospitalized with P&I. Additional measures are needed to reduce case-fatality associated with P&I in this population.

Medical illness and comorbidities in drug users: implications for addiction pharmacotherapy treatment

Providing effective medical care to those with substance use disorders can be a challenge to clinicians. In this article, we briefly summarize issues that occur frequently in the medical treatment of substance users. The focus of this article is twofold. The first is to briefly summarize common co-occurring medical illnesses in those manifesting substance use disorders with an emphasis on issues related to providing effective treatment for these diseases in this population. Using specific examples of frequently occurring comorbid medical illness in substance users, including infectious diseases (hepatitis C and HIV disease), sexually transmitted diseases, and pregnancy as examples, the complexities of medical care for this population is demonstrated. Second, this article addresses some of the difficulties encountered in pharmacotherapy aimed specifically at treatment of substance use disorders. For example, difficulties in managing concomitant opiate therapy in those requiring medications for medical illness that may have strong and adverse interactions with opiates are addressed. Adverse events reported for some substance use disorder pharmacotherapies are also highlighted. We conclude with a brief review of models of care that have been effective in addressing the needs of this challenging population that can provide additional means for enhancing the clinical care of substance users.