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Published in final edited form as: AIDS Care. 2021 Jul 12;34(2):135–144. doi: 10.1080/09540121.2021.1951646

A Systematic Review of Engagement in Care and Health Care Utilization among Older Adults Living with HIV and Non-communicable Diseases

Moka Yoo-Jeong 1,*, Ashley Anderson 2, Brittany “Ray” Gannon 3, Rebecca Schnall 4
PMCID: PMC8752641  NIHMSID: NIHMS1722646  PMID: 34251920

Abstract

Management of HIV has shifted from addressing acute AIDS-defining conditions to co-morbid non-communicable diseases. With aging persons living with HIV in the US, it is critical to understand health care engagement and utilization among older persons living with HIV (OPWH) who may have greater burden for non-communicable diseases. A systematic literature review was conducted to appraise and synthesize the current evidence on the relationship of co-morbid, non-communicable diseases on engagement in care and health care utilization among OPWH. Following the PRISMA guidelines, an electronic search of 5 databases was conducted. Original quantitative and qualitative studies published in English between 2009 and 2019 were included, yielding 16 relevant articles. Studies used a comprehensive checklist of non-communicable diseases (n=3), a validated measure for co-morbidities (n=4), or focused on specific chronic condition diagnoses including hypertension, diabetes, and chronic kidney disease (n=5). Included studies focused on different stages of HIV care continuum, including antiretroviral (ART) initiation (n=1) and adherence (n=1), relationship between adherence to non-HIV medication and ART (n=2), association between HIV diagnosis and non-communicable disease care (n=3), and health care utilization (n=10). Overall, having co-morbid non-communicable diseases was associated with a decreased likelihood of initiating and adhering to ART. Being on ART and viral suppression were associated with better engagement in non-communicable disease care. Findings also suggest that an increasing number of co-morbidities is associated with higher health care utilization and financial burden. This review underscores the need for preventing and managing co-morbidities to enhance engagement in HIV care and that health care practitioners need to ensure that OPWH are engaged in care for both HIV and their co-morbid conditions by providing coordinated and integrated care.

Keywords: engagement in care, health care utilization, non-communicable diseases, chronic conditions, systematic review

INTRODUCTION

As advances in antiretroviral therapy (ART) have transformed HIV into a chronic disease (Harris, Rabkin, & El-Sadr, 2018; May et al., 2014), the focus of HIV management has shifted from acute AIDS-defining conditions to co-morbid, non-communicable diseases, including cardiovascular disease, liver disease, kidney disease, osteoporosis, and non-AIDS-related malignancies (Deeks, Lewin, & Havlir, 2013). Older persons living with HIV (OPWH) are at an increased risk for non-communicable diseases due to natural progression of aging, HIV infection itself, and the effects of ART (Negin et al., 2012; Zhao & Goetz, 2011). The Center for Disease Control (CDC) reports that about half of persons living with HIV in the United States were 50 years of age and older in 2016 (CDC, 2017) and it is estimated that this age group will represent over 70% of OPWH by 2020 (APA, 2019). Globally, the same trend in the growing prevalence of OPWH is occurring and is expected to increase over time (Autenrieth et al., 2018). Adults aging with HIV are also expected to have multiple co-morbidities, with an estimated 88% of PLWH projected to live with a chronic disease by 2030 in the United States and Italy (Smit et al., 2017). Similarly, prevalence of non-communicable diseases is expected to rise among PLWH in many regions including South Africa over the coming years (Oni et al., 2015).

With an ever-increasing number of older PLWH, there is a paramount need to better understand the relationship between non-communicable diseases on health care engagement and utilization among older PLWH. Older PLWH pose a significant socio-economic and healthcare burden (Harris, Rabkin, & El-Sadr, 2018) and optimal engagement in health care may assist in effective management of co-morbidities and potential prevention of sequelae, which may ultimately reduce costs and burdens on the healthcare system (van der Valk & Reiss, 2017). In general, having multiple non-communicable diseases is related to more health care utilization (Lehnert et al., 2011), but whether this holds true among older PLWH, who may have even higher burden of chronic conditions (van der Valk & Reiss, 2017), needs further exploration. While studies that explore the relationship between chronic conditions and health care utilization are emerging, a comprehensive synthesis of existing empirical evidence is lacking. Therefore, the goal of this review was to appraise and synthesize the available evidence from both quantitative and qualitative studies to assess the relationships among co-morbid non-communicable diseases, engagement in care, and health care utilization among older PLWH.

METHODS

This systematic review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (Moher et al., 2015).

We included quantitative and qualitative studies that were published in peer-reviewed journals between 2009–2019 in the English language. The population of interest were OPWH who are aged 50 or older. We included studies that had participants with a mean or median age of 50 years or had a majority representation of OPWH. The major independent variables were non-communicable diseases (Appendix A), defined by the World Health Organization (WHO, 2018), which had to be assessed by the study using clearly described methods. The major outcomes of interest were engagement in care and health care utilization and studies needed to report on one or the other as their outcome. Engagement in care was defined as one of the five elements of the HIV care continuum, including HIV testing, HIV diagnosis, retention in care, ART adherence, and viral suppression (Gardner, McLees, Steiner, Del Rio, & Burman, 2011). Health care utilization was defined as “the quantification or description of the use of services by persons for the purpose of preventing and curing health problems” (Carrasquillo, 2013). Based on this definition, studies were included if health care utilization measures reflected health services use.

We excluded studies focusing specifically on psychiatric and neurocognitive conditions. Experimental and quasi-experimental study designs, case series, editorials, letters to the editor, commentaries, literature reviews, books and book chapters, research protocols, publications without primary data, unpublished manuscripts, and conference abstracts were excluded.

We conducted a literature search of PubMed, CINAHL, EMBASE, PsycInfo, and PsycNET for articles published from January 1, 2009 to October 1, 2019. A range of keywords related to co-morbidities, engagement in care, health care utilization, healthcare costs, HIV/AIDS, and older adults were searched. A detailed search strategy for each database is available in Appendix B. Two reviewers independently evaluated the titles and abstracts, followed by full-text review. When either of the two reviewers considered a study potentially eligible or uncertain, we reviewed the full-text for further assessment. A third reviewer resolved any disagreements or discrepancies. One reviewer extracted data from included studies.

The Joanna Briggs Institute’s (JBI) critical appraisal tool was used to rate the scientific rigor of individual studies (JBI, 2017). The JBI tools appraise the rigor of the methods and results of published studies based on the research designs. Two reviewers independently rated the studies and any discrepancies between raters were resolved via inter-rater discussion or by involving a third reviewer.

RESULTS

Figure 1 provides the PRISMA flow diagram for the literature review screening and selection process. The database search identified 1,382 publications, resulting in a total of 1,298 unique titles after removing duplicates. We screened the full-text of 99 publications against the inclusion and exclusion criteria and excluded 83 publications that did not meet our inclusion criteria. A total of 16 studies were included in this review and a description of their characteristics and measures are in Appendix C.

Figure 1.

Figure 1.

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PRISMA Flow Diagram.

NCD = non-communicable disease; EIC = engagement in care; HCU = healthcare utilization; PLWH = persons living with HIV

The review included studies from six different countries, including Australia (Edmiston, Petoumenos, & Smith, 2018), Kenya (Kiplagat, Mwangi, Chasela, & Huschke, 2019), South Africa (Chang et al., 2019; Knight, Schatz, & Mukumbang, 2018; Manne-Goehler et al., 2017; Manne-Goehler et al., 2019), the United Kingdom (De Francesco et al., 2019; Patel et al., 2016), Ireland (De Francesco et al., 2019), and the United States (Abara, Adekeye, Xu, Heiman, & Rust, 2016; Abara, Adekeye, Xu, & Rust, 2017; Abara et al., 2014; Batchelder, Gonzalez, & Berg, 2014; Monroe, Rowe, Moore, & Chander, 2013; Quinn, Sanders, & Petroll, 2017; Weiss et al., 2016; Zingmond, Arfer, Gildner, & Leibowitz, 2017). Studies used cross-sectional (n=7), cohort (n=5), and qualitative (n=4) designs. Three studies used the same parent study that enrolled both HIV negative and positive patients from a rural setting in South Africa (Chang et al., 2019; Manne-Goehler et al., 2017; Manne-Goehler et al., 2019) and these studies compared HIV care continuum to the non-communicable disease care continuum. Four studies used Center for Medicare and Medicaid Services claims data (Abara et al., 2016; Abara et al., 2017; Abara et al., 2014; Zingmond et al., 2017). One qualitative study was conducted in rural counties in the United States (Quinn et al., 2017) and the remainder of the studies conducted in the United States were from urban settings.

Quality of Included Studies

Detailed results of the quality assessment can be found in Figures 2A–2C. All but one of the cross-sectional studies met every quality appraisal item. This study (Patel et al., 2016) did not use a validated and reliable measure to assess independent/dependent variables of interest. The quality of one prospective cohort study (Weiss et al., 2016) was poor.

Figure 2A.

Figure 2A.

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Quality of Included Studies: Cross-Sectional Design

Figure 2C.

Figure 2C.

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Quality of Included Studies: Qualitative Design

All four of the qualitative studies did not address the components of trustworthiness in qualitative research (Morse, 2015), including use of a reflexive statement that identifies the position of the researchers and experience with the communities/phenomena (Koch & Harrington, 1998). This process of self-appraisal helps ensure identification of inherent bias (Creswell, 2013; Koch & Harrington, 1998). One qualitative study (Knight et al., 2018) was rated poorly due to lack of addressing issues of congruity and researcher bias or influence.

Non-communicable Diseases and Engagement in Care

Engagement in care was guided by the five elements of the HIV care continuum: 1) HIV testing, 2) HIV diagnosis, 3) retention in care, 4) ART adherence, and 5) viral suppression (Gardner et al., 2011). Of the studies that assessed the relationship between non-communicable diseases and engagement in care, two studies focused on ART initiation (Abara et al., 2014) and ART adherence (Abara et al., 2016); two studies compared non-communicable diseases medication adherence to ART adherence (Batchelder et al., 2014; Weiss et al., 2016); and three studies assessed the association between HIV diagnosis or being on ART and engagement in care related to non-communicable diseases (Chang et al., 2019; Manne-Goehler et al., 2017; Manne-Goehler et al., 2019).

ART initiation and adherence

One study (Abara et al., 2014) assessed the effects of having a non-communicable disease on ART initiation within 90 days after HIV diagnosis. Participants who had one or more non-communicable diseases were significantly less likely to initiate ART within 90 days than were participants who did not have non-communicable diseases even after adjusting for covariates. In a separate study, individuals with non-communicable diseases were less likely to adhere to ART (Abara et al., 2016); participants with non-communicable disease were significantly less likely to have optimal ART adherence than those without non-communicable diseases.

Adherence to co-morbid non-communicable disease medications and ART

Participants were more likely to adhere to ART than other non-communicable disease medications (Batchelder et al., 2014). A study that compared anti-diabetic medication adherence to ART adherence among OPWH with type II diabetes mellitus (Batchelder et al., 2014) found that, on average, participants reported maintaining 95% adherence to ART compared to 90% adherence to anti-diabetic medications. In the same study, only 37% of participants reported perfect adherence to antidiabetic medications, whereas 48% percent reported perfect adherence to ART. Similarly, a study that compared chronic kidney disease and hypertension medication adherence to ART adherence (Weiss et al., 2016) found that although adherence rate did not differ, patients were more adherent to the timing of their ART than to the timing of their antihypertensive medication.

Qualitative study findings also revealed some challenges with patients living with non-communicable diseases and having to take multiple medications. Qualitative study participants described that non-communicable diseases were a major source of concern and frustration (Monroe et al., 2013), and viewed these conditions as more important and urgent than HIV (Kiplagat et al., 2019). Study participants with multiple co-morbid conditions living in a rural setting had difficulties keeping track of their medications, remembering the indication for the medication, and the refill dates (Quinn et al., 2017). On the other hand, a study conducted in an urban setting found that some study participants were motivated to adhere to their medications due to their co-morbid conditions and symptoms (Monroe et al., 2013).

HIV diagnosis and engagement in non-communicable disease care

Three cohort studies, which used the same dataset from South Africa, found that being dually diagnosed with a non-communicable disease and HIV is positively associated with non-communicable diseases care. A study (Chang et al., 2019) assessed the engagement in HIV and non-communicable disease care and found that individuals with dual diagnoses of hypertension and HIV were more likely to be engaged in their hypertension care, but there was no effect on the engagement in HIV care. In contrast, those with HIV and co-morbid cardiometabolic conditions (dyslipidemia, angina) had less progression in the stages of HIV care compared to those without such conditions.

Two studies compared the diagnoses of hypertension or diabetes on engagement with non-communicable disease care (Manne-Goehler et al., 2017; Manne-Goehler et al., 2019) and found that ART use was significantly associated with greater odds of access to hypertension and diabetes screening and treatment compared to HIV-positive individuals not on ART and HIV-negative individuals. Additionally, being on ART and having undetectable viral load (VL) was associated with greater awareness of hypertension diagnosis and treatment (Manne-Goehler et al., 2017). Among those with diagnosed hypertension or diabetes, those on ART with undetectable VL was associated with lower mean systolic blood pressure and lower mean glucose levels, indicating better control of their co-morbid conditions (Manne-Goehler et al., 2019).

Non-communicable Diseases and Health Care Utilization

In two qualitative studies conducted in Kenya and South Africa, chronic conditions among OPWH were cared for by multiple health care providers or at different health care facilities (Kiplagat et al., 2019; Knight et al., 2018). These findings were no different in a study of rural counties in the United States where participants reported numerous challenges in maintaining their health care due to the lack of local care providers and the need to travel to access care (Quinn et al., 2017).

In the included studies that used quantitative approach, it was found that an increasing number of co-morbid conditions is significantly associated with higher overall health care utilization (Patel et al., 2016), an increased likelihood of an ED visit (Abara et al., 2017), and a longer duration of or incident hospitalization (Abara et al., 2017; Edmiston et al., 2018). Additionally, having certain types of co-morbid conditions, particularly cardiovascular disease (De Francesco et al., 2019; Edmiston et al., 2018) and malignancy (Edmiston et al., 2018), as well as drug use (Patel et al., 2016) was associated with increased hospitalization.

One quantitative study found that an increasing number of co-morbidities are associated with higher healthcare costs (Zingmond et al., 2017) and that there are challenges that come with financial burden of taking multiple medications and having multiple visits to healthcare services (Quinn et al., 2017). Zingmond et al. examined health care expenditures for outpatient services, pharmaceuticals, and inpatient services separately and found that with an increased number of co-morbidities, mean and median spending per capita for total costs for each health care service also increased. In qualitative studies, participants who reported receiving Medicare/Medicaid voiced their struggles in paying for medications especially during the beginning of the year (Zingmond et al., 2017) that they were selective in medication purchasing at the expense of forgoing basic needs.

DISCUSSION

Despite the growing number of persons aging with HIV who are now living with non-communicable co-morbid conditions, there is limited evidence on the relationship between living with these conditions and engagement in care. Our review found some evidence that OPWH who are living with more co-morbid non-communicable diseases are less likely to engage in their HIV care but those diagnosed with certain co-morbid conditions and who are engaged in HIV care are more likely to be engaged in their non-HIV care related to their co-morbid conditions. Findings from this review also suggest that patients are more adherent to their ART medications than non-HIV medications and as OPWH experience more co-morbid conditions, there is higher utilization of healthcare services.

OPWH with an increasing number of co-morbidities were less likely to be engaged in their HIV care, including less likely to initiate and adhere to ART (Abara et al., 2016; Abara et al., 2014). Additionally, having a particular condition was related to less engagement in HIV care (Chang et al., 2019). These findings may be partially explained due to frailty, being unable to coordinate care, and psychological implications of living with HIV and multiple co-morbid conditions. Patients with multiple co-morbid conditions are more likely to be frail (Fried et al., 2001) and therefore may be physically unable to manage additional appointments, laboratory and pharmacy visits. Further, patients with multimorbidity and especially those living with HIV often suffer from co-existing psychological conditions, including depression, which can further compound their physiological conditions (Havlik, Brennan, & Karpiak, 2011; Read, Sharpe, Modini, & Dear, 2017). These psychological symptoms can further exacerbate the levels of adherence to ART and engagement in HIV care (Bengtson et al., 2018).

Challenges related to medication adherence were also noted from the included studies. While OPWH were more likely to adhere to ART than to their non-HIV medications (Batchelder et al., 2014; Weiss et al., 2016), many individuals raised concerns with difficulties in managing multiple conditions, making adherence to their medications challenging (Monroe et al., 2013; Quinn et al., 2017). Polypharmacy rates are higher among OPWH than the general population (Guaraldi et al., 2018) and OPWH reporting polypharmacy have lower treatment satisfaction and concerns related to drug-drug interactions and side effects (Okoli et al., 2020). It is therefore essential to assess patient-level, patient-provider level, and patient-system level barriers to adherence to multiple medications (Osterberg & Blaschke, 2005) and identify targets for enhanced shared clinical decision making surrounding optimal management of multiple conditions.

This review provides some evidence that OPWH who are engaged in their HIV care are more likely to be engaged in their care related to non-communicable co-morbid condition. As compared to OPWH who are not on their ART medications and to patients who are not living with HIV, OPWH who are on their ART medications and have viral suppression were better engaged in their overall healthcare related to non-communicable diseases (Manne-Goehler et al., 2017; Manne-Goehler et al., 2019). The context of these studies was in a rural setting in South Africa. Being diagnosed with HIV in this setting may mean that they may be more aware of and have better access to healthcare than those who are not diagnosed with HIV. Whether these study findings hold true across different settings need further exploration. We can also speculate that especially those who are long-term survivors of HIV may be more resilient and can cope with their conditions well since they have endured for many years managing their medication regimens, which were very complicated and cumbersome at the beginning of the epidemic (Emlet, Tozay, & Raveis, 2011). Further, these patients have also successfully navigated the healthcare system for decades, so it is logical that they are much better prepared to adapt to and balance the challenges of navigating more than one diagnosis as compared to an older adult who has been newly diagnosed with a non-communicable disease and has had little life experience navigating the healthcare system. Future studies should include assessment of duration of HIV diagnosis, the impact of the setting that the patients live in, and the level of engagement in the healthcare and management of co-morbid conditions.

Finally, our review summarizes from existent literature that as the number of co-morbidities among OPWH increased, there was an increase in health care utilization (Abara et al., 2017; De Francesco et al., 2019; Edmiston et al., 2018; Kiplagat et al., 2019; Knight et al., 2018; Patel et al., 2016; Quinn et al., 2017) and expenditure (Knight et al., 2018; Quinn et al., 2017; Zingmond et al., 2017). While an increase in co-morbidities will likely increase overall cost due to the increase in laboratory services and medication (Knight et al., 2018; Zingmond et al., 2017), there is also the opportunity to contain costs through coordinated care (Khullar & Chokshi, 2018; Kimmel et al., 2018). Training HIV specialists to manage complex co-morbid conditions or training generalists to manage routine HIV care can minimize costs by reducing the number of patient visits. Importantly this can also reduce the financial, physical, and psychological burden on OPWH living with non-communicable co-morbid conditions by reducing the need for them to coordinate their care and travel to multiple visits with different healthcare providers.

This systematic review is not without limitations. The data that is currently available is quite sparse providing a number of challenges in providing more meaningful conclusions. First, the data was collected from six countries in which the healthcare systems are not comparable and likewise the HIV epidemic in the United States is vastly different than the epidemic in Africa, with the United States population being much older and much lower rates of new cases. Additionally, healthcare systems are different according to countries, limiting the direct comparison across studies that were conducted in different countries. Second, the data sources are comprised of cross-sectional, cohort, retrospective, and qualitative studies making it difficult to synthesize the findings from these different study types in a meaningful way. Finally, the search was restricted to the past 10 years, the English language, and populations aged 50 and older; therefore, we may have missed studies that were relevant to our research question during the literature search. While it may be possible our search terms missed relevant research, the fact that we only identified sixteen that met our inclusion criteria is noteworthy.

Conclusions

This systematic review found evidence that increasing co-morbid non-communicable diseases in OPWH is associated with less engagement in HIV care but those who are optimally engaged in HIV care are more likely to be engaged in their care for non-communicable diseases. Findings from this review also suggest that patients are more adherent to their ART medications than non-HIV medications and as OPWH experience more co-morbid conditions, there is higher utilization of healthcare services. Our small sample indicates that the topic of co-morbid chronic conditions on health care engagement and utilization are emerging and not well described in the published literature, which warrants the need for further rigorous exploration.

Supplementary Material

Appendix A,B
Appendix C

Figure 2B.

Figure 2B.

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Quality of Included Studies: Cohort Design

ACKNOWLEDGEMENTS

This study was supported by the National Institute of Nursing Research of the National Institutes of Health under the following award numbers: T32NR014205, T32NR007969, K24NR018621. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We would like to thank John Uselligo, Health Informationist at Columbia University, for his input on the search strategy and review of this systematic review’s methodology.

Footnotes

Disclosure Statement. None of the authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

Contributor Information

Moka Yoo-Jeong, Northeastern University, Bouvé College of Health Sciences, School of Nursing, Boston, Massachusetts, USA..

Ashley Anderson, Columbia University School of Nursing, New York, New York, USA..

Brittany “Ray” Gannon, Columbia University School of Nursing, New York, New York, USA..

Rebecca Schnall, Columbia University School of Nursing, New York, New York, USA..

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix A,B
NIHMS1722646-supplement-Appendix_A_B.doc (37KB, doc)
Appendix C
NIHMS1722646-supplement-Appendix_C.doc (66.5KB, doc)

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