Access to HIV Medication in the Community Versus a Nursing Home for the Medicare Eligible HIV population

Systematic Review: HIV, Aging, and Housing-A North American Perspective, 2012-2023

Advances in anti-retroviral therapy (ART) have decreased mortality rates and subsequently led to a rise in the number of HIV-positive people living longer. The housing experiences of this new population of interest-older adults (50 years and older) living with HIV-are under-researched. Understanding the housing experiences and unmet needs of older people with HIV can better provide comprehensive care services for them. This study's systematic review evaluated the peer-reviewed literature reporting housing access/insecurity/assistance/options, housing impact, and unmet needs of older individuals living with HIV in North America from 2012 to 2023. Furthermore, Latent Semantic Analysis (LSA), a text-mining technique, and Singular Value Decomposition (SVD) for text clustering were utilized to examine unstructured data from the abstracts selected from the review. The goal was to allow for a better understanding of the relationships between terms in the articles and the identification of emerging public health key themes affecting older adults living with HIV. The results of text clustering yielded two clusters focusing on (1) improvements to housing and healthcare services access and policies and (2) unmet needs-social support, mental health, finance, food, and sexuality insecurities. Topic modeling demonstrated four topics, which we themed to represent (1) a holistic care approach; (2) insecurities-food, financial, sexuality, and other basic needs; (3) access to housing and treatment/care; and (4) homelessness and HIV-related health outcomes. Stable housing, food, and healthcare services access and availability are critical elements to incorporating comprehensive, holistic healthcare for older adults living with HIV. The aging population requires high-priority policies for accessible and equitable healthcare. Clinicians and policymakers should address individual barriers, adopt a patient-centered approach, increase doctor visits, provide competency training, ensure long-term follow-up, involve families, and improve patient education in care management, contributing to HIV/AIDS geriatric care models.

Geriatric Conditions Associated with Nonadherence to Antiretroviral Therapy Among Older People with HIV: The Importance of Frailty

Poor compliance with medications is a growing concern in geriatric care and is increasingly more relevant among people living with HIV (PLWH) as they age. Our goal was to understand geriatric conditions associated with antiretroviral therapy (ART) nonadherence in a Medicare population of older PLWH. We analyzed Medicare data from PLWH aged 50 years or older who were continuously enrolled in fee-for-service Medicare from January 1, 2014 to June 30, 2015. Prevalent geriatric conditions (dementia, depression, falls, hip fracture, sensory deficits, osteoporosis, orthostatic hypotension, urinary incontinence, frailty) were identified in January 1, 2014-December 31, 2014. ART nonadherence was defined as <80% proportion of days covered (PDC) by at least two ART medications in January 1, 2015-June 30, 2015. We examined geriatric condition association with nonadherence using lowest Akaike Information Criterion multi-variate logistic models, controlling for age, sex, race, census region, substance use, Medicaid eligibility, and polypharmacy. Of 8778 PLWH, 23% (n = 2042) had <80% PDC. The average age was 60 years (standard deviation ±8), and >70% were males. In adjusted models, age was not associated with nonadherence, frailty status was the only geriatric condition associated with nonadherence [robust: reference, prefrail odds ratio (OR): 0.97, confidence interval (95% CI) 0.86-1.10, frail OR: 1.34 95% CI 1.11-1.61], and odds of nonadherence were lower for polypharmacy [OR: 0.48 (0.43-0.54)]. Our findings suggest that patient-centered care plans aimed at improving ART adherence among older PLWH would benefit from long-term surveillance; a deeper understanding of the role of frailty and polypharmacy, even at chronologically younger ages in PLWH.

Economic Barriers to Antiretroviral Therapy in Nursing Homes

OBJECTIVES

Our aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). Medicare Part A pays NHs a bundled skilled nursing rate that includes prescription drugs for up to 100 days, after which individuals are responsible for the costs.

DESIGN

A cross-sectional study.

SETTING

NHs.

PARTICIPANTS

A total of 694 newly admitted long-stay (>100 d) NH residents with HIV.

MEASUREMENTS

We used Minimum Dataset v.3.0, pharmacy dispensing data, NH provider surveys, and Medicare claims from 2011 to 2013. We assessed receipt of any HIV antiretrovirals or recommended combinations (ART), as defined by national care guidelines, and the source of payment. We identified predictors of antiretroviral use with risk-adjusted generalized estimating equation logistic models.

RESULTS

All study persons living with HIV/AIDS in NHs had prescription drug coverage through Medicare's Part D program, and ART was 100% covered. However, only 63.9% received recommended ART, and 15.2% never received any antiretrovirals during their NH stay. The strongest predictor of not receiving antiretrovirals was the first 100 days of a long NH stay (odds ratio [OR] = .44; 95% confidence interval [CI] = .24-.80). The strongest predictor of receiving recommended ART was health acuity (OR = 1.51; 95% CI = 1.20-1.88).

CONCLUSION

People living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers. J Am Geriatr Soc 68:777-782, 2020.