The proportion of nursing home residents living with HIV in the United States has increased markedly in recent years, but the facilities they are admitted to tend to be of poorer quality, researchers from Brown University report in two articles in the Journal of the American Geriatrics Society. One third of residents have some form of dementia or cognitive impairment.
Many nursing homes have little experience of caring for people with HIV. Disparities in the quality of nursing home care have already been documented for gay people and ethnic minorities. In addition, more people living with HIV live in low-income neighbourhoods whose nursing homes are known to often provide a lower quality of care.
However, little is known about the use of nursing homes by people living with HIV and the quality of care they receive. The researchers therefore analysed data from Medicare and Medicaid, the US public programmes that provide health coverage to older people, those with a disability and people with low incomes.
For the first analysis, Professor Susan Miller and colleagues focused on the 14 states that account for 75% of the HIV prevalence in the United States: New York, California, Florida, Texas, Maryland, New Jersey, Pennsylvania, Illinois, Georgia, North Carolina, Virginia, Louisiana, Ohio, and Massachusetts.
Between 2001 and 2010, there were 9,245,009 people who stayed in nursing homes for at least 90 days. In 2001, 0.7% had HIV, rising to 1.2% by 2010. In the five highest-prevalence states, the figure was 2.0% in 2010 (New York, New Jersey, Maryland, Louisiana and Florida). If these trends have continued, the current figure in those five states is likely to be around 4%.
Six per cent of residents under the age of 65 were living with HIV, compared to 0.5% of those over that age. On average, HIV-positive residents were younger (60 years vs 80 years) than those without HIV. This could be partly due to health problems occurring at an earlier age. But it also reflects the fact that there are relatively few people living with HIV in their seventies or eighties in the wider community.
Residents living with HIV were also more likely to be black (51% vs 14%) and male (68% vs 33%).
Common diagnoses in those living with HIV included depression (39%), cognitive impairment (33%), diabetes (28%), cerebrovascular accidents (19%), chronic obstructive pulmonary disease (COPD, 15%), congestive heart failure (13%), renal failure (12%), anxiety (10%), schizophrenia (9%), atherosclerosis (6%), cancer (6%) and bipolar disorder (5%).
Particularly for cognitive impairment, it is important to consider people’s ages. In all age groups, the prevalence of Alzheimer’s disease was lower in people with HIV than those without. For example, in those aged 55 to 64 years, it was around 1% in those with HIV and 4% in those without. In those aged 75 to 84, the figures were 15% and 19% respectively.
For other forms of dementia, including vascular cognitive impairment and HIV-associated cognitive disorder, this pattern was reversed – although the differences were not large. In those aged 55 to 64 years, around 23% of nursing home residents with HIV had another form of dementia and 20% of those without HIV had it. In those aged 75 to 84, the figures were around 43% and 38% respectively.
Quality of care
David Meyers are colleagues, also from Brown University, have looked at the quality of nursing homes that serve people with HIV. For this analysis, data were available for nine of the previously mentioned states.
A total of 4178 nursing homes were included. Between 2001 and 2012, they admitted 6,631,275 people, including 67,301 people living with HIV.
Over half of nursing homes did not serve any people living with HIV at all, and the majority of people with HIV went to a facility with relatively few residents living with HIV. However, comparing residents who live in the same geographic area (county) as each other, people with HIV were more likely to go to a home with a greater concentration of HIV-positive residents than would be expected by chance alone.
Moreover, these nursing homes tended to have poorer quality ratings, including a lower star rating (on Medicare’s Nursing Home Compare website), more deficiencies noted by regulators, and a higher rate of hospital re-admission after discharge from the nursing home.
This was particularly true of the group of those nursing homes in which between 5 and 50% of their residents were living with HIV. Their ratings were poorer than those of homes serving fewer people with HIV or none at all. These homes represent less than 5% of the facilities surveyed but look after a third of the residents living with HIV.
In contrast, quality scores were good for 13 specialist facilities (all in New York or Florida) in which over half of residents were living with HIV (in fact, an average of 94% were living with HIV). The average star rating and deficiency count for these facilities were better than for any other group of nursing homes.
The researchers say that one possible explanation for the lower quality scores of homes serving large numbers of people with HIV is a ‘neighbourhood effect’ – people living with HIV tend to live in low-income neighbourhoods near poorer-quality nursing homes. Another possibility, they say, is that hospital discharge planners steer patients with HIV towards facilities with a larger number of other residents living with HIV and these are of poorer quality.
“As the concentration of HIV in a nursing home increases, nursing home quality appears to be lower, with the exception of a subset of nursing homes with high HIV concentrations,” the researchers conclude. “Given increasing aging among the national population of patients with HIV, more efforts are needed to ensure people living with HIV are admitted to higher-quality nursing homes.”
Miller SC et al. Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use. Journal of the American Geriatrics Society 67: 1353-1360, 2019. https://doi.org/10.1111/jgs.15949
Meyers DJ et al. The Quality of Nursing Homes That Serve Patients With Human Immunodeficiency Virus. Journal of the American Geriatrics Society, online ahead of print, 2019. https://doi.org/10.1111/jgs.16155