San Francisco, on the West coast of the United States, has around 884 000 residents and is home to 16 000 people living with HIV1. The epidemic is largely concentrated among key populations, with gay men and other men who have sex with men accounting for 74% of new diagnoses annually2. Strong leadership and community engagement have resulted in state-of-the-art HIV services, and new HIV
diagnoses in the city fell from 458 in 2012 to 221 in 2017. The city is also in reach of global treatment goals, at 94–79–941.
In the 1980s, San Francisco was one of the first cities to feel the full impact of the HIV epidemic. More recently, it has also witnessed the transformation of HIV from a fatal disease to a chronic one: currently, 60% of all people living with HIV in the city are over the age of 50 years, and 25% are aged 65 or older3.
1 San Francisco. In: Fast-Track Cities Global Web Portal [Internet]. IAPAC; c2019 (http://www.fast-trackcities.org/cities/san-francisco, accessed 27 August 2019).
2 HIV Statistics: San Francisco. In: sfaf.org [Internet]. San Francisco; San Francisco AIDS Foundation (SFAF); c2019 (https://www.sfaf.org/resource-library/hiv-statistics/, accessed 27 August 2019).
3 HIV epidemiology annual report 2017. San Francisco: Health SFDoP; 2018.
Aging with HIV
Although the provision of treatment and care has been very successful, there are new challenges. Adults living with HIV are at increased risk for other conditions, such as cardiovascular disease, osteoporosis, renal disease and certain cancers; this often results in the need for multiple treatments1,2,3,4. Older adults living with HIV also experience geriatric conditions, such as falls and frailty, at relatively younger ages than people who do not have HIV5,6. In addition, older adults living with HIV often are from marginalized populations and are dealing with mental health conditions and psychosocial issues, such as loneliness, substance use and related stigmas7,8,9. HIV care models for those aging with HIV therefore need to expand their focus beyond virologic suppression to improving quality of life and providing care for comorbidities. Merging principles from both geriatric and HIV fields have been proposed as a way of developing new and holistic models of care for people aging with HIV10,11.
Ward 86 clinic
San Francisco General Hospital’s Ward 86 has a tradition of leading and innovating in HIV care since it first opened its doors in 1983. This includes ersearch that led to the use of universal antiretroviral therapy in 2010, starting a PrEP programme in 2013 and making the rapid start of antiretroviral therapy (on day of diagnosis) the standard of care since 2012. It also developed a new programme for homeless patients in 2019.
Ward 86 offers a comprehensive range of medical and psychosocial services to approximately 2600 low-income and uninsured HIV-positive patients throughout San Francisco. Of these patients, more than 1200 are aged 50 years or older. The clinic already has a structure of multidisciplinary provision of care that provides an ideal foundation for a new model of care for its aging population, and in 2017, the clinic developed a comprehensive care programme known as the Golden Compass to address their needs.
The Golden Compass program
Staff at the clinic designed the Golden Compass programme on HIV and aging with input from patients and providers12. The name of the programme came from ideas raised in focus group discussions with patients: “golden years” was the acceptable term for aging across all groups, and many participants indicated that they needed further guidance on how to navigate their care. The Golden Compass concept is therefore structured around helping people living with HIV navigate their golden years, with each compass point focused on a specific challenge facing this population:
■ Heart and mind (North): on-site cardiology, cognitive evaluations and brain health classes.
■ Bones and strength (East): bone health, fitness and physical function, including exercise and wellness classes and on-site geriatric consultation.
■ Dental, hearing and vision (West): appropriate screenings and linkage to services.
■ Networking and navigation (South): social and community-building activities, including a storytelling class for participants.
Participants keep their primary care provider, but they also have access to on-site, HIV-focused specialty care from a geriatrician and cardiologist, in addition to other programmes.
Evaluation
The Golden Compass programme at Ward 86 was launched in January 2017. An evaluation after the first 18 months showed that 220 patients had participated in at least one part of the programme. Through surveys and interviews with patients and primary care providers, the evaluation found that patients, providers and staff were highly satisfied with the program: more than 90% reported that they were “satisfied” or “very satisfied” with it. Similarly, 90% of staff and providers felt the programme had improved the health of older adults at Ward 86. Overall, both patients and providers found the programme highly acceptable (96%), although providers did note that patients, especially those in their 50s, did not like to discuss aging.
With regard to specific services, more than 90% of providers expressed satisfaction with the cardiology and geriatrics clinics, noting improvements in patient care and consultations. Services to address problems related to multiple medications and mobility also were valuable for both patients and providers: participants reported improvements in their balance, posture and mental health from the exercise classes, and many participants also indicated that they formed new connections with other patients during these classes.
In one example, a man in his mid-60s who had been living with HIV for a number of years noted a number of benefits from the focused programming of the Golden Compass. His dizziness resolved after his medications for blood pressure and prostate
were adjusted, and he was better able to deal with feelings of grief and isolation. He also felt much better after being connected with a volunteer at a local community-based AIDS organization and making friends through the Golden Compass classes, and he
noticed decreased stiffness from the exercise classes. Overall, he said, “I’m in a good place compared to how I was before I started in the program.”
Expanding the reach
Work is ongoing to expand the reach of the programme to ensure that ageappropriate screenings for HIV and other geriatric conditions occur for all people over the age of 50. Alternative options for Golden Compass consultations—including e-consultations, telemedicine and other models—are also being explored. In addition, the clinic is developing training programmes on aging-related topics and assessments for staff and providers in order to reduce dependence on the geriatric consultant and to impart generalizable skills to a greater number of providers who are caring for the clinic’s aging population.
1 Greene M, Justice AC, Lampiris HW, Valcour V. Management of human immunodeficiency virus infection in advanced age. JAMA. 2013;309(13):1397-1405.
2 Greene M, Steinman MA, McNicholl JR, Valcour V. Polypharmacy, drug-drug interactions, and potentially inappropriate medications in older adults with human immunodeficiency virus infection. J Am Geriatr Soc. 2014;62(3):447-53.
3 Freiberg MS, Chang CC, Kuller LH, Skanderson M, Lowy E, Kraemer KL et al. HIV infection and the risk of acute myocardial infarction. JAMA Intern Med. 2013;173(8):614-22.
4 Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS. 2006;20(17):2165-74.
5 Erlandson KM, Plankey MW, Springer G, Cohen HS, Cox C, Hoffman HJ et al. Fall frequency and associated factors among men and women with or at risk for HIV infection. HIV Med. 2016;17(10):740-8.
6 Greene M, Covinsky KE, Valcour V, Miao Y, Madamba J, Lampiris H et al. Geriatric syndromes in older HIV-infected adults. J Acquir Immune Defic Syndr. 2015;69(2):161-7.
7 Green TC, Kershaw T, Lin H, Heimer R, Goulet JL, Kraemer KL et al. Patterns of drug use and abuse among aging adults with and without HIV: a latent class analysis of a US veteran cohort. Drug Alcohol Depend. 2010;110(3):208-20.
8 Grov C, Golub SA, Parsons JT, Brennan M, Karpiak SE. Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care. 2010;22(5):630-9.
9 Johnson Shen M, Freeman R, Karpiak S, Brennan-Ing M, Seidel L, Siegler EL. The intersectionality of stigmas among key populations of older adults affected by HIV: a thematic analysis. Clin Gerontol. 2019:42(2):137-49.
10 Singh HK, Del Carmen T, Freeman R, Glesby MJ, Siegler EL. From one syndrome to many: incorporating geriatric consultation into HIV care. Clin Infect Dis. 2017;65(3):501-6.
11 Guaraldi G, Rockwood K. Geriatric-HIV medicine is born. Clin Infect Dis. 2017;65(3):507-9
12 Greene ML, Tan JY, Weiser SD, Christopoulos K, Shiels M, O’Hollaren A et al. Patient and provider perceptions of a comprehensive care program for HIV-positive adults over 50 years of age: the formation of the Golden Compass HIV and aging care program in San
Francisco. PLoS One. 2018;13(12):e0208486.