Multimorbidity among people with HIV in regional New South Wales, Australia

Communication and coordination of care for people living with HIV: a qualitative study of the patient perspective

BACKGROUND

There is growing consensus that primary health care (PHC) providers have an important role in providing holistic, preventative care for people living with human immunodeficiency virus (PLHIV). In regional Australia, HIV care is primarily delivered through specialist services, thus adequate coordination and communication between specialist and PHC professionals is crucial. This study aimed to explore patient experiences of the coordination of care and health care professional communication for PLHIV in regional Australia.

METHODS

Semi-structured interviews with PLHIV in a regional area of Australia were conducted in March to April 2022. Interviews were conducted via video conferencing, face-to-face, or via telephone call. Interviews were audio-recorded and manually transcribed. Transcripts were coded inductively and thematic analysis was conducted to explore perspectives on communication and coordination.

RESULTS

Thirteen participants were interviewed. Most participants were male, aged 50-70, were diagnosed with HIV more than ten years ago, and had been living in regional Australia long-term. Through qualitative analysis, themes emerged in the following areas: (1) Patient perception of care coordination; (2) Patient understanding of modality of communication; (3) Positive attitudes towards communication between healthcare professionals; and (4) Concerns for information sharing between healthcare professionals. Many participants highlighted lack of clarity around care coordination as a key issue in their healthcare, with some citing themselves as the primary care coordinator. Participants identified that coordination and communication between PHC professionals and specialist services are essential in the delivery of their health care, but some were hesitant for this to occur. Hesitancy was entrenched in some patients' distrust of healthcare due to previous experiences of confidentiality breaches and stigma.

CONCLUSION

This study identifies the need for clarity in coordination between health care professionals to deliver safe and effective HIV care, which may occur through care plans. Patient support for communication between healthcare providers may be strengthened by ensuring trust in the people and systems involved. Eliminating stigma in healthcare as well as building more trustworthy electronic-based communication technologies are essential components to trust-building between PLHIV and healthcare systems.

Validation of the combined Patient Health Questionnaire Anxiety and Depression Scale among people with HIV in Vietnam

BACKGROUND

Our study aims to examine the factor structure, validity, and reliability of the combined scale Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) among people with HIV (PWH) in Vietnam.

METHODS

Baseline data from an alcohol-reduction intervention trial among ART clients in Thai Nguyen, Vietnam were used for this analysis (n = 1547). A score ≥10 on the PHQ-9, GAD-7 and PHQ-ADS scale was considered having clinically meaningful depression, anxiety and distress symptoms. Factor structure of the combined PHQ-ADS scale was validated using confirmatory factor analysis, and three models were tested: a one-factor, a two-factor, and a bi-factor model. Reliability and construct validity were examined.

RESULTS

The prevalence of clinically meaningful depression and anxiety symptoms was 7% and 2%, respectively, while 19% had distress symptoms. A bi-factor model had the best fit to the data (RMSEA = 0.048; CFI = 0.99; TLI = 0.98). The Omega index of the bi-factor model was 0.97. The scale showed good construct validity through negative associations between depression, anxiety, distress symptoms and quality of life.

CONCLUSIONS

Our study supports the use of a combined scale to measure general distress for PWH, which has good validity, reliability and is unidimensional enough to justify the use of a composite depression and anxiety score.

Determinants of access to general practice in a shared care model for people living with HIV: a qualitive study of patients' perspectives in an Australian rural community

BACKGROUND

Improved management of human immunodeficiency virus (HIV) has resulted in improved life expectancy for people living with HIV and an ageing population with a significant comorbidity burden. Shared care models, involving the co-ordinated liaison between general practitioners and specialist physicians, have been advocated for in Australia to provide comprehensive care. People living with HIV in rural areas have reduced access to general practice and therefore shared care. This study explores the perspectives of people living with HIV on the barriers and enablers to accessing shared care in an Australian rural setting.

METHODS

In this qualitative study, semi-structured interviews were conducted with adults living with HIV who either resided in or accessed care in a rural area of Australia. Interviews were conducted via video conferencing, phone or face-to-face. Transcripts were imported into NVivo, coded and analysed in alignment with a conceptual framework of healthcare access defined by Levesque and colleagues.

RESULTS

Thirteen interviews were conducted in total. Participants' narratives demonstrated the substantial influence of accessibility to general practice on their ability to engage in effective shared care. Challenges included the perception that general practitioners would not provide additive value to participants' care, which restricted the ability to both seek and engage in the shared care model. Healthcare beliefs, expectations and experiences with stigma led participants to prioritise the perceived interpersonal qualities of specialist care above a shared care system. Access to shared care was facilitated by continuity of care in general practice but logistical factors such as affordability, transport and availability impacted the ability to access regular high-quality healthcare.

CONCLUSIONS

Navigating patient priorities and anticipated stigma in general practice within the resource limitations of rural healthcare were barriers to effective shared care. General practitioners' ability to build rapport and long-term relationships with participants was instrumental in the perception of valuable care. Strategies are required to secure continuity of care with interpersonally skilled general practitioners to ensure provision of quality primary care for people living with HIV, which can be supported by specialist physicians in a shared care model.

What are the predictors of change in multimorbidity among people with HIV? A longitudinal observational cohort study

INTRODUCTION

Multimorbidity is common among people living with HIV (PLWH), with numerous cross-sectional studies demonstrating associations with older age and past immunosuppression. Little is known about the progression of multimorbidity, particularly in the setting of long-term access to antiretrovirals. This study aims to determine factors predictive of change in multimorbidity in PLWH.

METHODS

People living with HIV who attended a regional HIV service were recruited to a consented observational cohort between September 2016 and March 2020. Demographic data, laboratory results and a Cumulative Illness Rating Scale (CIRS) were collected at enrolment and first clinical review of every subsequent year. Change in CIRS score was calculated from enrolment to February 2021. Associations with change were determined through univariate and multivariate linear regression.

RESULTS

Of 253 people, median age was 58.9 [interquartile range (IQR): 51.9-64.4] years, 91.3% were male, and HIV was diagnosed a median of 22.16 years (IQR: 12.1-30.9) beforehand. Length of time in the study was a median of 134 weeks (IQR: 89.0-179.0), in which a mean CIRS score change of 1.21 (SD 2.60) was observed. Being older (p < 0.001) and having a higher body mass index (p = 0.008) and diabetes (p = 0.014) were associated with an increased likelihood of worsening multimorbidity. PLWH with a higher level of multimorbidity at baseline were less likely to worsen over time (p < 0.001).

CONCLUSION

As diabetes and weight predict worsening multimorbidity, routine diabetes screening, body mass index measurement, and multimorbidity status awareness are recommended.

Defining multimorbidity in people with HIV - what matters most?

PURPOSE OF REVIEW

Although multimorbidity (defined as the coexistence of multiple conditions) presents significant health challenges to people with HIV, there is currently no consensus on how it should be defined among this population. This review aimed to examine the definition of multimorbidity in existing studies among people with HIV ( n  = 22).

RECENT FINDINGS

Variation in the definition of multimorbidity (in terms of the number and nature of conditions included) across studies among people with HIV was observed, with less than half (45%) reporting a selection criteria for conditions. The number of conditions considered ranged from 4 to 65. Certain conditions (e.g. stroke, myocardial infarction and chronic kidney disease) and risk factors (e.g. hypertension) were more frequently included, while other symptoms (e.g. joint pain, peripheral neuropathy and sleeping problems) and mental health conditions (e.g. anxiety and panic attacks) were rarely included in the definition of multimorbidity.

SUMMARY

The definition of multimorbidity among people with HIV is highly variable, with certain conditions overlooked. We propose recommendations that researchers should consider when defining multimorbidity among this population to not only enable comparisons between studies/settings but also to ensure studies consider a person-centred approach that can accurately capture multimorbidity among people with HIV.

‘The spiral just keeps on going’: Cascading health and social issues for women living and aging with HIV

Background:

There has been limited qualitative inquiry aimed at understanding the gendered and unique experiences of women living with HIV in high-income countries. In Australia, the relatively small number of women living with HIV means they have been largely overlooked in social, clinical, and policy representations of HIV over time.

Objectives:

To explore the experiences of women living long-term and aging with HIV, to understand the complex intersections between their health and social trajectories.

Methods:

Data were collected as part of Living Positive in Queensland, a longitudinal qualitative study of the experiences of living long-term and aging of people living with HIV in Queensland, Australia. This study analysed data from three annual, semi-structured interviews with the 11 female participants.

Results:

Women negotiated gendered roles and identities as they grappled with ongoing and intertwined health and psychosocial challenges over their life course. Development of co-morbidities, experiences of stigma, gendered social roles, financial precarity, and limited social support amplified the challenges of living with HIV and cumulatively impacted women’s health and wellbeing as they aged with HIV.

Conclusion:

The health and wellbeing of women living with HIV are adversely impacted by intersecting complex health issues, HIV-related stigma, gendered identities, social disadvantage, and aging. Greater attention to the unique needs of women living with HIV is necessary to reduce the prevalence of psychological distress, financial stress, and vulnerability to social isolation which, in turn, lead to poorer health.

Polypharmacy and potential drug-drug interactions for people with HIV in the UK from the Climate-HIV database

Objectives

People with HIV (PWHIV) are likely to need therapies for comorbidities as they age. We assessed risk of drug–drug interactions (DDIs) in PWHIV.

Methods

The Climate‐HIV electronic recording system was used to cross‐sectionally analyse records from PWHIV aged ≥ 18 years attending four UK HIV units with a current antiretroviral (ARV) prescription in February 2018. Antiretroviral and non‐ARV medications were categorized by clinical significance of DDIs (University of Liverpool DDI tool). Potential DDIs were predicted using treatment guidelines for commonly recorded comorbidities.

Results

Among 4630 PWHIV (44% female), 41% were ≥ 50 years old. The average number of non‐ARV comedications increased from < 1 for patients aged ≤ 24 years to > 5 for patients aged ≥ 75 years; 65% were taking one or more non‐ARV comedications. The median (interquartile range) number of non‐ARVs was 1 (0–2) and 2 (1–5) for those aged < 50 and ≥ 50 years, respectively. Common comorbidities/concurrent health conditions occurred more frequently in patients aged ≥ 50 years vs. < 50 (53% vs. 34%). Boosted protease inhibitors were associated with the highest proportion of contraindicated comedications; dolutegravir and raltegravir had the fewest. For non‐ARVs, sildenafil and quetiapine were most likely to result in DDIs. Guideline‐recommended treatments for hepatitis C, hepatitis B, and tuberculosis had the highest proportions of contraindications when combined with ARV regimens, while treatments for hepatitis C, malignancy, and mental health conditions had the highest proportion of combinations potentially causing DDIs requiring dose monitoring or adjustment.

Conclusions

Non‐ARV use by PWHIV is high and increases with age. Treatment decisions for ageing PWHIV should consider guideline recommendations for comorbidities.

Assessing the Measurement Properties of the Fitbit Zip® Among Adults Living With HIV

PURPOSE

To assess the criterion and construct validity of the Fitbit Zip® to measure physical activity among adults living with HIV.

METHODS

Participants were video recorded completing 2 walk tests while wearing the Fitbit Zip® and completed 3 self-reported physical activity questionnaires 1 week later. The authors calculated intraclass correlation coefficients (ICCs) to determine agreement between the number of steps taken and distance walked (Fitbit Zip®) with the visual count of number of steps taken and actual distance walked (walk tests). The authors tested 15 a priori hypotheses about predicted associations between questionnaire scores and physical activity measured by the Fitbit Zip®.

RESULTS

Among the 34 participants, there was "excellent" agreement between the number of steps taken measured by the Fitbit Zip® and visually counted number of steps taken (ICC = .99) and number of steps taken at slow (ICC = .75), moderate (ICC = .85), and fast (ICC = .78) walking speeds. There was "poor" agreement between the Fitbit Zip® recorded distance and actual determined distance walked (ICC = .20). Three (20%) construct validity hypotheses were confirmed.

CONCLUSIONS

The Fitbit Zip® demonstrated criterion validity for its ability to measure number of steps taken but not distance walked, and did not demonstrate construct validity for measuring physical activity among adults with HIV.

Chronic Diseases Multimorbidity among Adult People Living with HIV at Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia

Background

Due to the wide implementation of antiretroviral therapy (ART), people living with HIV (PLWHIV) are now living longer. This increased the risk of developing noncommunicable chronic diseases (NCCDs) among them.

Objective

We aimed to describe prevalence of NCCDs multimorbidity among PLWHIV at Hawassa University Comprehensive Specialized Hospital (HUCSH).

Method

In April 2016, institution-based cross-sectional study was conducted among PLWHIV, aged ≥ 18 years at the ART unit of HUCSH. A nurse working in the ART unit interviewed patients and reviewed medical records. Data on the NCCDs and its risk factors were obtained. List of diseases considered in this study were arthritis, diabetes mellitus, hypertension, congestive heart failure (CHF), rheumatic heart diseases (RHD), chronic bronchitis, asthma, and cancer.

Results

More than half of the respondents (196) had at least one of the NCCDs and 34 (8.9%) had multimorbidity. The main system of the body affected were the musculoskeletal system, 146 (38.2%) and respiratory system, 46 (12.0%). There was no significant difference in the prevalence of individual NCCDs by gender. Patients aged above 44 years, patients with ART duration of at least 6 years, and patients with higher CD4 counts had increased odds of having any one of the NCCDs. Multimorbidity patients with a longer ART duration had an increased risk.

Conclusion

The prevalence of NCCD multimorbidity among PLWHIV was high. Monitoring the occurrence of NCCDs among PLWHIV and noncommunicable disease care is recommended.

Multimorbidity, not human immunodeficiency virus (HIV) markers predicts unplanned admission among people with HIV in regional New South Wales

BACKGROUND

Multimorbidity and unplanned admissions are common among people with human immunodeficiency virus (PWH).

AIMS

To determine factors predictive of unplanned admission among PWH in regional New South Wales and compare care coordination between people with and without unplanned admissions.

METHODS

A prospective cohort study of PWH attending a regional human immunodeficiency virus (HIV) service was conducted. Baseline HIV-specific results and multimorbidity markers including Cumulative Illness Rating Scale (CIRS) were assessed as predictors of time to first unplanned admission using Cox regression analysis. Care coordination markers were compared between people with and without unplanned admission, using χ² statistic for proportions and t-test for means.

RESULTS

A cohort of 181 PWH was followed for a maximum of 5 years. During a total of 739 person-years of follow up, 39 (20.6%) patients reached the endpoint of unplanned admission. In multivariate analysis, the baseline CIRS score was predictive of unplanned admission (P < 0.001). Age, HIV-specific markers and missed visits were not predictive of unplanned admission. For patients with an unplanned admission, discharge summaries were documented for 22/39 (56.4%). Of 180 PWH with a visit after baseline, 131 (72.8%) had a letter to a general practitioner and 79 (43.7%) had two or more prescribers. Having two or more prescribers was more common in people with an unplanned admission than in those without (64.1% vs 38.0%, P = 0.004).

CONCLUSION

Unplanned admission among PWH is predicted by multimorbidity. Care for PWH should include coordinated management of other health conditions in order to reduce their severity and prevent unplanned admissions.

Motivations and Barriers to Treatment Uptake and Adherence Among People Living with HIV in Australia: A Mixed-Methods Systematic Review

In Australia, approximately 30% of people diagnosed with HIV are not accessing treatment and 8% of those receiving treatment fail to achieve viral suppression. Barriers limiting effective care warrant further examination. This mixed-methods systematic review accessed health and social sector research databases between November and December 2015 to identify studies that explored the perspective of people living with HIV in Australia. Articles were included for analysis if they described the experiences, knowledge, attitudes and beliefs, in relation to treatment uptake and adherence, published between January 2000 and December 2015. Quality appraisal utilised the Mixed Methods Appraisal Tool Version 2011. Seventy-two studies that met the inclusion criteria were reviewed. The interplay of lack of knowledge, fear, stigma, physical, emotional and social issues were found to negatively impact treatment uptake and adherence. Strategies targeting both the individual and the wider community are needed to address these barriers.

Are you ready? Exploring readiness to engage in exercise among people living with HIV and multimorbidity in Toronto, Canada: a qualitative study

OBJECTIVES

Our aim was to explore readiness to engage in exercise among people living with HIV and multimorbidity.

DESIGN

We conducted a descriptive qualitative study using face-to-face semistructured interviews with adults living with HIV.

SETTING

We recruited adults (18 years or older) who self-identified as living with HIV and 2 or more additional health-related conditions from a specialty hospital in Toronto, Canada.

PARTICIPANTS

14 participants with a median age of 50 years and median number of 9 concurrent health-related conditions participated in the study. The majority of participants were men (64%) with an undetectable viral load (71%).

OUTCOME MEASURES

We asked participants to describe their readiness to engage in exercise and explored how contextual factors influenced their readiness. We analysed interview transcripts using thematic analysis.

RESULTS

We developed a framework to describe readiness to engage in exercise and the interplay of factors and their influence on readiness among adults with HIV and multimorbidity. Readiness was described as a diverse, dynamic and fluctuating spectrum ranging from not thinking about exercise to routinely engaging in daily exercise. Readiness was influenced by the complex and episodic nature of HIV and multimorbidity comprised of physical impairments, mental health challenges and uncertainty from HIV and concurrent health conditions. This key factor created a context within which 4 additional subfactors (social supports, perceptions and beliefs, past experience with exercise, and accessibility) may further hinder or facilitate an individual's position along the spectrum of readiness to exercise.

CONCLUSIONS

Readiness to engage in exercise among people living with HIV is a dynamic and fluctuating construct that may be influenced by the episodic nature of HIV and multimorbidity and 4 subfactors. Strategies to facilitate readiness to exercise should consider the interplay of these factors in order to enhance physical activity and subsequently improve health outcomes of people with HIV and multimorbidity.

Mental health problems in people living with HIV: changes in the last two decades: the London experience 1990-2014

Mental health problems continue to be a significant comorbidity for people with HIV infection, even in the era of effective antiretroviral therapy. Here, we report on the changes in the mental health diagnoses based on clinical case reports amongst people with HIV referred to a specialist psychological medicine department over a 24-year period, which include the relative increase in depressive and anxiety disorders, often of a chronic nature, together with a decline in acute mental health syndromes, mania, and organic brain disorders. In addition, new challenges, like the presence of HIV and Hepatitis C co-infection, and the new problems created by recreational drugs, confirm the need for mental health services to be closely involved with the general medical services. A substantial proportion of people with HIV referred to specialist services suffer complex difficulties, which often require the collaboration of both psychiatrists and psychologists to deal effectively with their difficulties.