Retention, relinking and return to care
For people with HIV to achieve optimal health outcomes, they must receive ongoing care over their lifetime. Missed clinic visits and other gaps in care are associated with increased mortality, reduced cART adherence, increased hospitalization and lapses in ability to manage comorbidities.158, 159 Patients, especially those with complex needs, may experience interruptions in care.160
A number of indicators have been proposed to measure patient retention in care, including clinic encounters/visits, timing of VL or CD4 tests, and test results during a calendar year.161, 162 Most recently in Ontario, care engagement in any year was defined as:
- “in care” – at least 1 viral load or CD4 cell count
- “continuous care” – at least 2 viral loads or CD4 cell counts at least 90 days apart.
- “being on ART” – based on prescription medication recorded in medical charts.163
However, laboratory tests and pharmacy records may not provide a complete picture of retention and engagement in care for clinical purposes164 or document co-/multi-morbidity care provided at different locations.
Although there is evidence to support some clinic and provider-initiated retention strategies, there is often not enough data to assess their impact on biological outcomes. Data are also lacking on effective techniques to: re-engage people in care after they have been lost to follow-up; follow patients over many years; or address the needs of specific populations.165–167 The following recommendations include both evidence-based interventions and “promising practices” to enhance retention.
Care for persons with HIV >50 years of age
The relationship between HIV and aging is still unclear. Does a lifetime of HIV and use of cART result in “accelerated” aging? Or are the frequency and burden of conditions associated with aging “accentuated” in people with HIV? Regardless of etiology, the growing number of people with HIV who are >50 – particularly those who acquired HIV much earlier in life (long-term survivors) – require thoughtful clinical management187 that addresses a nexus of health and psychosocial risks, including:
- multimorbidity and related polypharmacy
- comorbidity risks for liver disease (not confined to association with hepatitis), dyslipidemia and cardiovascular disease, kidney impairment or other organ injury, male benign prostatic hypertrophy and some cancers
- “frailty” and “pre-frailty” (weight loss, diminished gait and grip, exhaustion, low energy) and the function loss associated with aging
- long-term effects of “survivorship,” stigma, substance use, and mental health and cognition challenges
- social isolation, economic vulnerability or need for coping skills.187–195
While much of the management of aging-related conditions will be similar in people with HIV as in general population, clinics/practices should target specific health risks faced by older patients with HIV (e.g. hypertension, fecal occult blood testing, CVD, COPD, Type 2 diabetes, cancer, neurocognitive impairments).16, 196 As people with HIV age and receive care at home or in hospitals or long-term care settings, special attention should also be paid to co-infections, depression and substance use.197, 198