HIV patients' use of health care system on rise due to diseases of ageing

HIV-positive patients are beginning to utilise more health care system time for conditions such as cardiovascular disease, a Danish study published in the online edition of AIDS suggests. The researchers believe that this is likely to be because of the ageing of patients with HIV.

Thanks to the success of antiretroviral therapy, the study showed that there was a substantial and sustained fall in hospital admissions for patients with HIV.

Antiretroviral treatment means that many HIV-positive patients are likely to live a normal lifespan.

There have been changes in the types of diseases causing illness and death in individuals with HIV. Those related to HIV have become less important causes of morbidity and mortality whereas treatment side-effects, the normal diseases of ageing, and co-infections have become more important.

Improvements in health thanks to HIV therapy mean that there have been important changes in the way HIV-infected individuals access health care.

Fewer patients are being admitted to hospital, but there is increasing demand for out-patient services. Moreover, the type of specialist outpatient services used by patients has also changed, with a greater reliance on clinics for non-infectious diseases.

Danish investigators wished to gain a better understanding of the impact of HIV treatment on the use of in-patient and out-patient services. They therefore studied the use of such facilities between 1995 and 2007. This use was compared to that observed in the general Danish population.

The study sample included all 4760 HIV-infected individuals in Denmark and 26,000 controls who were matched for age and sex.

A total of 34,000 person-years of follow-up were available for analysis. HIV was diagnosed in 40% of patients before 1995, an 24% died. Three-quarters were men, 80% were white. Median age at the start of the study was 34 years, 40% were gay men and 11% injecting drug users. HIV treatment was taken by 73% of individuals.

Between 1995 and 2007 there was a 61% increase in the number of patients accessing HIV services each year.

There was also a significant ageing in the population. The number of patients aged under 50 increased by 31%, but there was a 600% increase in the number of patients aged between 50 and 60.

The number of inpatient admission days fell by 43% between 1995 and 2007. At the same time, the yearly number of out-patient appointments increased by 127%.

Compared to the general Danish population, the risk of inpatient admission for individuals with HIV fell from 6.2 in the period 1995-97 to 3.1 in 2004-07.

Inpatient admissions for infectious diseases fell for patients with HIV from 96 per 100 person years to 18 per 100 person-years. There was also an initial fall in admissions for non-infectious diseases, but this stabilised at a rate of 35 per 100 person-years.

Rates of inpatient admissions for cancer increased amongst people with HIV, but fell in the general population.

Although admissions for cardiovascular disease increased in both HIV-positive patients and controls, the rate of increase was much more marked for those with HIV (76% vs. 46%). The investigators calculated that individuals with HIV were therefore 50% more likely to be admitted to hospital for this reason than their age and sex-matched controls.

Overall attendance for outpatient appointments by people with HIV increased by 17%. The number of outpatient appointments with non-infectious diseases specialists increased by 175%.

There was a marked decline in the risk of attending outpatient appointments with a cancer specialist (8.0 to 2.6), but there was a 50% increase in the risk of patients with HIV needing an outpatient appointment at a cardiovascular clinic.

“We found that the overall utilisation of inpatient services by the Danish HIV-infected population fell dramatically after the introduction of HAART, whereas it continued to increase for outpatient services, especially at non-infectious disease specialiaties”, write the investigators.

Nevertheless, in 2007 HIV-positive patients still had an inpatient admission rate three times that seen in the general Danish population.

Cardiovascular disease and other diseases of ageing were important reasons for admissions, and these conditions also necessitated outpatient appointments.

The investigators note that this is to be expected given the ageing of their cohort.