The databases search yielded a total of 5699 unique citations, from which 151 articles were selected for full text review. Of these 151 articles, 12 peer-reviewed articles were included. An additional peer-reviewed article was obtained from hand searching. No grey literature was included. Thirteen articles were included in the final analysis (see Fig. 1 PRISMA flow chart).
Most (n = 10/13, 77%) of the publication activity occurred in the United States (USA)31 39 41 59–65. The remaining three articles (n = 3/13,23%) were from the United Kingdom (UK)66–68. Over half (n = 9/13,69%) of the articles were published in the last 5 years (2018–2023) 31 39 41 60–62 65 67 68. In published papers, the most common research methods were qualitative. The key description from these studies were abstracted and are summarized in Table 1.
Table 1
Study details, organized alphabetically by author name.
Author (year), Country
|
Objective(s)
|
Sample Size, Time Period
|
Patient Sex (n)
|
Patient Ethnicity, n (%)
|
Patient Age, Median or Mean, Range in Years
|
Healthcare Professional Roles Involved in Care
|
Intervention (Program Name)
|
Bitas (2019),
USA
|
To describe the recommendation patterns that arose from the CGA in a population of HIV-infected older adults, and to assess the adherence to XXXrecommendation during a 6-month follow-up.
|
76 people, June 2013-July 2017
|
52 Male, 24 Female
|
40.8% African American
34.2% White
22.4% Latino
|
50+
Median age 67.2
|
HIV specialist (infectious diseases or internal medicine physician)
Social worker,
Psychiatrist
Dietician
Geriatrician
|
Comprehensive geriatric assessment (CGA) for older people at a HIV clinic.
|
Cresswell (2017), UK
|
To describe how widespread HIV services are in the UK and how they are organized.
|
102 HIV clinics,
Time Period NR
|
N/A
|
N/A
|
N/A
|
Physician
HIV clinical nurse specialist
Clinical psychologist
Dietician
Social worker
Physiotherapist
Occupational therapist
|
Electronic survey of HIV clinics using SurveyMonkey.
|
Davis (2021), USA & UK
|
To describe strengths and weaknesses of various models of geriatric consultation for older adults living with HIV.
|
NR
|
NR
|
NR
|
50+
|
Model 1: Geriatrician; HIV provider
Model 2: Physician; Geriatrician with HIV training
Model 3: Dual-trained provider with expertise in geriatrics & HIV
|
Model 1: Outpatient consultation.
Model 2: Combined HIV/geriatric multidisciplinary clinic.
Model 3: Dual-trained provider consultation.
|
Garvey (1994), USA
|
To describe issues in an existing model of care for elderly people with AIDS and suggest improvements.
|
NR
|
NR
|
NR
|
50+
|
Registered nurse (case manager)
Social worker
Counselor
Therapist
Nutritionist
Home care aide
Medical director
Chaplain, volunteer(s)
|
Community-based delivery of hospice and home care with an on-call system. (AIDS home care and hospice model of Visiting Nurses and Hospice of San Francisco).
|
Greene (2018), USA
|
To describe qualitative data from patients and providers that informed the development of a comprehensive care model for older people living with HIV.
|
77 patients and 26 providers, March-April 2016
|
53 Male, 19 Female,
5 Transgender
|
50.6% Black
26% Non-Hispanic White
11.7% Latino
7.8% Other
|
50+
Median age 58
Range 50–77
|
Administration
Nurse
Medical assistant
Nurse practitioner
Physician
|
Focus groups and surveys to identify the most important health issues and/or needs facing older adults with HIV.
|
Greene (2020), USA
|
To evaluate the initial implementation of the Golden Compass program at San Francisco General Hospital.
|
198 adults,
January 2017-June 2018.
|
178 Male, 20 Female
|
39% White
22% Black
7% Asian
5% American Indian/Alaska Native
17% Hispanic
|
50+
Mean age 62
|
Physician
Medical director, Cardiologist
Geriatrician
Registered nurse
Pharmacist
Program coordinator Medical assistant.
|
Implementation of a geriatric-HIV program using the RE-AIM framework (Golden Compass).
|
Heckman (2010), USA
|
To test if a coping improvement group intervention could reduce depressive symptoms in persons over 50 years of age living with HIV/AIDS.
|
295 patients, 12 x weekly sessions with 4 and 8 month follow up
|
197 Male, 96 Female
|
48% African American
|
50+
Mean age 55.3
|
NR
|
12 face-to-face group sessions on coping improvement.
|
Heckman (2017), USA
|
To determine trajectories of symptom change from two group tele-therapies for older people living with HIV and depression.
|
105 patients, 12 week treatment period
|
Coping enhancement group: 28 Male, 26 Female
Supportive-expressive group: 22 Male, 27 Female
|
Coping enhancement group: 27.3% White, 72.7% Persons of color
Supportive-expressive group: 10.2% White, 89.8% Persons of color
|
Coping enhancement group: Mean age of 57.86
Supportive-expressive group: Mean age of 58.97
|
Therapist
|
12 weekly sessions of tele-therapy that were either 1) coping enhancement or 2) supportive-expressive.
|
Levett (2020), UK
|
To describe the CGA approach used in a multidisciplinary HIV ageing clinic and the results of an initial evaluation of the clinic.
|
52 patients, 2016–2019
|
47 Male, 5 Female
|
96% White
|
Mean age 67
Range 53–87
|
HIV physician
Geriatrician
HIV nurse specialist
HIV pharmacist
|
Comprehensive Geriatric Assessment (CGA) used in an outpatient clinic (Silver Clinic).
|
Ruiz (2010), USA
|
To describe the development of a geriatrics HIV screening program for patients over 60 years in an urban clinic; to report its initial results; and to discuss options for further development.
|
17 referred to the program. Evaluations were done from May 2007 to May 2009. Target group selected in July 2009. Further screenings done yearly.
|
9 Male, 8 Female Referred to program
|
NR
|
60+
Mean age 62.6
|
Dual-trained geriatrician/HIV specialist
Social worker
Pharmacist
Nurse practitioner
|
Geriatric screening evaluations and subsequent referral to a geriatric HIV intervention program.
|
Schmalzle (2022), USA
|
To describe the initiation and early outcomes of a new care geriatric model for older people with HIV.
|
58 patients, March-June 2019
|
59% Male, 41% Female
|
95% African American
|
Mean age 59
Range 50–73
|
Social worker
Pharmacists
Physician
|
HIV primary and speciality care clinic in Baltimore, MD, USA (THRIVE Program).
|
Siegler (2018), USA
|
To examine clinical programs for older people living with HIV internationally and compare their models.
|
N/A
|
N/A
|
N/A
|
50+
N/A
|
Geriatrician
Psychologist
Pharmacist
|
N/A
|
Tan (2021), USA
|
To explore the impact of the Golden Compass program from the perspectives of both patients and primary care providers.
|
13 patients, 11 primary care providers, October 2018-May 2019
|
Patients:
11 Male, 2 Female
Providers: NR
|
Patients: 46.2% Black, 23.1% Other, 23.1% White, 15.4% Latnix, 7.7% Native Hawaiian/Pacific Islander
Providers: NR
|
50+
\
|
HIV geriatrician
Cardiologist
Pharmacist
General practitioner
|
Implementation of a geriatric-HIV program using the RE-AIM framework (Golden Compass).
|
Patient Population
Patients in the included models of care ranged from 4860-87 years of age67. The number of patients served ranged from 7639 over 4 years to a maximum of 4000 at the time of data collection (period unspecified)66. Of those articles that reported sex (n = 9/13,69%), the majority described primarily male samples39 60–65 67 68. Articles that reported race/ethnicity (n = 7/13, 54%), described including participants who were mostly White60 61 67 or African American39 62 63 65 68. These articles all included White individuals. Of the two (n = 2/13, 15%) studies that reported the median time since HIV diagnosis39 63, the average was 12.563–21.539 years. Medicaid was used as the patients’ primary health insurance in the USA39 61 62.
Key Operational Components of Geriatric Models of HIV Care
The qualitative analysis identified three distinct model of care components, each with one or more sub-components. These components are listed and described in Table 2. Table 2 also lists the articles adherent to each component. These model components are described below and are illustrated in Fig. 2.
Table 2
Description of Model Components
Model Component
|
Description
|
Model Component 1: Collaboration and Integration
|
The organization and scheduling of planned care amongst various providers in health and community sectors to ensure effective intervention and care. Care is coordinated across healthcare and community settings.
|
i) Multidisciplinary Care Roles
|
The involvement of healthcare providers from various disciplines in the delivery of care and the assignment of key roles among team members.
|
ii) Team-Based Care
|
Providers working collaboratively as a team with defined tasks and responsibilities to provide effective care.
|
iii) Community Linkages
|
How a model of care connects with community programs and services, and the partnerships formed with community organizations to deliver care and support.
|
Model Component 2: Organization of Geriatric Care
|
The structures, procedures and policies of the healthcare system in which a geriatric model of care takes place.
|
i) Staffing Models
|
The organization of healthcare professionals within a model of care.
|
ii) Access and Referrals
|
How individuals living with HIV can access geriatric and specialized care, and the referral process to be seen by care providers.
|
iii) Implementation of Evidence-Based Screening
|
The use of validated screening instruments to inform high-quality care.
|
Model Component 3: Pillars of Holistic Care
|
How a model of care meets physical, spiritual, mental and social needs.
|
i) Comprehensive Geriatric Assessment
|
Any activities involved in the Comprehensive Geriatric Assessment of an older adult, with a particular focus on identifying and addressing geriatric syndromes.
|
ii) Supporting Self-Management
|
Any activities or strategies that help older adults living with HIV manage their own health concerns and be actively involved in their care.
|
Table 3. Model Adherences, organized by study author name
Author (year)
|
1.Collaboration & Integration
|
1.1 Multidisciplinary Care Roles
|
1.2 Team-Based Care
|
1.3 Comm-unity Linkages
|
2.Organization of Geriatric Care
|
2.1 Staffing Models
|
2.2 Access and referals
|
2.3 Implement-ation of Evidence-Based Screening
|
3. Pillars of Holistic Care
|
3.1 Comprehensive Geriatric Assessment
|
3.2 Supporting Self-Management
|
Bitas (2019)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Creswell (2017)
|
Yes
|
Yes
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Davis (2022)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Garvey (1994)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Greene (2018)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Greene (2020)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Heckman (2010)
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Heckman (2017)
|
No
|
No
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Levett (2020)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
Ruiz (2010)
|
Yes
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
Schmalze (2022)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Siegler (2018)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Tan (2021)
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Model Component 1: Collaboration and Integration
Eleven (n = 11/13, 85%)31 394159–6164–68 articles described the importance of collaboration and integration for providers caring for older adults with HIV. Models of care frequently incorporated a team of multidisciplinary professionals from the health and social care sectors that were linked in with community supports to improve healthcare delivery for older adults with HIV. We describe these sub-components below.
i) Multidisciplinary Care Roles
Multidisciplinary teams supported the care of older adults living with HIV in all eleven articles that adhered to the Collaboration and Integration model component (n = 11/13, 85%). These articles described several provider roles, including designated HIV specialists (infectious diseases or internal medicine physicians)39 41 60 61 65–68, geriatricians39 41 60 61 64 65 67 68 and/or dual-trained HIV and geriatric physicians. Other physician roles included psychiatrists39, endocrinologists65, cardiologists41 60 61 68 and medicine fellows64. Numerous nursing roles41 59–61 64 65 were involved, such as HIV clinical nurse specialists41 66 67 and nurse practioners41 64 65. Allied health professionals included dieticians39 65 66/ nutritionists41 59, social workers39 41 59 61 65 66 68, phsysiotherapists41 59 66, occupational therapists41 59 66, speech-language pathologists59, counselors/therapists59, homecare aides59, clinical psychologists65 66 and specialist pharmacists41 60 65–67.
In addition to healthcare providers, several models of care also included research team members (i.e. research coordinators39, research assistants39, graduate students in gerontology and epidemiology41), medical directors and administrative staff59 61 (e.g., program coordinator60, a gerontologist [i.e., non-clinician]41), chaplains59 and volunteers59. Peer navigator roles were also described31 41 65 68.
The key responsibilities of these providers differed between models of care and many had overlapping functions. Physicians 39 41 60 61 64–68 and nurses41 59–61 64 65 were often responsible for overseeing and ensuring appropriate medical care, such as disease and symptom management. Other healthcare professional roles and designated navigation-specific roles31 65 68, provided medication, rehabilitation41 59 66, dietary39 59 65 66, or emotional counseling to patients and caregivers59. Geriatricians, in particular, provided evidence-based, best-practice advice that was shared with patients’ primary care providers39 41 60 61 64 65 67 68. HIV specialists generally oversaw HIV-related treatments and community services39 41 60 61 65–68. Pharmacists often provided medication instructions and explained care protocols41 60 65–67. All care providers were described as providing informational and tangible (i.e., hands-on care) support. Administrative and research staff were responsible for documenting relevant information accurately39 41 59 61. Only one article mentioned the role of non-professional caregivers (i.e., spouse, partner, or friend) as part of the care team59, in which they were described as providing much of the personal care involved in the home management of HIV59.
Administrative team members and researchers support the collection of client information to systematically standardize clinical and research operations39 41 59–61.
ii) Team-Based Care
Ten articles (n = 10/13, 77%) described the team-based delivery of multidisciplinary care, which was facilitated by several different mechanisms. Informational continuity was identified as being vital in ensuring a consistent and coherent approach to the management of older adults’ evolving needs67. A shared electronic health record was found to enable team-based care, including the ability for multiple providers to chat in real-time31 41 60 61 68. Moreover, the multidisciplinary team would often meet to discuss each patient’s background, their outcome measures, current clinical problems, and anticipated needs31 41 60 61 67 68. Consequently, the team would facilitate the appropriate screenings through access to different providers, services, and resources31 39 41 60 61 65 68. Following a referral and initial clinical visit, the HIV-geriatric specialists would maintain communication with the primary care team31 39 61 64 67 68, make recommendations based on the identified age-related needs for care31 39 60 67, initiate referrals to other specialist care providers and communicate with community stakeholders to meet other needs59 68 69. Team-based care allowed for all members of the circle of care to have a comprehensive knowledge of patients’ health and social care needs (e.g., functional, cognitive)31 39 59 61 65. Results from retrospective medical and pharmacy chart reviews helped inform all team decisions65. When deemed necessary, the team would be able to create a new action plan39 68 and determine follow-up64 68. Nurses who worked in case manager roles helped to facilitate this care by coordinating a comprehensive, holistic care plan in collaboration with the patient, caregiver(s), physician(s), and other members of the care team 59. Team-based models of care were felt to improve the coordination of care41 67.
iii) Community Linkages
Nine articles (n = 9/13, 69%) described how the management of HIV in older adults involved active, collaborative partnerships between multidisciplinary healthcare providers and the various community resources available to individuals living with HIV. Models of care were often delivered in linkage with community resources (e.g., social groups) 415965 and through community partners (e.g., volunteer organizations)41. Social workers often helped to facilitate community linkages5960, and grant-funding helped to pay for community services65. By working with community partners41, models of care were able to deliver both nonclinical care39 (e.g., peer support to decrease isolation and depression4167), as well as clinical care31 (e.g., care facilitated by a community nurse3941). Community outreach also helped to foster friendships amongst older adults living with HIV through social and community-building activities including dinners, speeches, dances, and trips 59. Local partner agencies assisted with meeting the housing needs for patients with marginal housing6165, and with the provision of legal services61. Partnering medical HIV-geriatric services with community services was thought to result in improved access to services3141, reduced social isolation606168, improved home safety management5968 and the provision of spiritual care such as priests, rabbis, or pastoral personnel59.
Model Component 2: Organization of Geriatric Care
The specific organizational structure of each model of care varied, particularly as it related to staffing models, processes for access and referrals, and the implementation of evidence-based, best-practice care and follow-up. All articles adhered and contributed to this model component. Models of care were often delivered through clinics that were predominantly hospital-based (i.e., operating within a hospital)39 60 61 65–67. Additionally, geriatric clinics were outpatient clinics housed within existing HIV clinics41 64 65 68 or community-based services providing home care59. Some models of care were able to be delivered virtually, either solely via phone62 or in addition to in-person delivery 65 66. Some clinics ran weekly66, bi-weekly65 or monthly41 65–67, whereas others were full-time39 65.
i) Staffing Models
Within the identified models of care, various staffing models were described. All articles contributed to this sub-component. The Geriatrician-Referral model included a geriatrician who consulted on patients39 41 60 61 64 65 based on a referral from the primary care team (often an HIV provider41), according to the perceived need (e.g., cognitive concerns). Six articles (n = 6/13, 46%) adhered to this. The Joint-Clinic model involved a geriatrician and HIV physician who were present in a single, combined clinic41 66–68. Four articles (n = 4/13, 31%) adhered to this model. The HIV-Physician-led model involved staffing clinics with a HIV physician and clinical nurse specialist trained in geriatrics, without geriatrician involvement65 66. Two articles (n = 2/13, 15%) adhered to this model. A further staffing model, the Dual-Trained Provider model, involved a dually-trained HIV and geriatrics provider, as either a physician41 68 or psychotherapist62 63. Four articles (n = 4/13, 31%) adhered to this model. The Nurse-led model, involved nurse-lead teams of allied health professionals59. Only one article (n = 1/13, 8%) adhered to this model59.
ii) Access and Referrals
All articles described processes to ensure appropriate access to care, and thus contributed to this sub-component. Referrals and on-call services59 were used to facilitate access to care5960. In some models of care, older adults were only able to access geriatric services via a referral from their HIV primary care team3941606167, while in other models, referrals were triggered by a combination of age (i.e., 50 years of age or older) and need (e.g., complexity)3166–68. The process of receiving geriatric care often began with an assessment of patients’ needs and functional status (e.g., cognition)3964 and the collection of demographic information (e.g., age, sex, race/ethnicity, HIV risk factors, marital status, insurance status39)316165. Provider referrals were often documented through tracking scheduled appointments606168, however, limitations of this method included HIV providers not remembering to refer41 and patient barriers such as confusion over the need for the referral which may result in skipping geriatric appointments41. One model of care implemented patient reminders to help ensure appointments were attended64. Two articles (n = 2/13, 15%) relied on referrals through an AIDS service organization62 63Moreover, across the models, patients could choose to be referred to one service (e.g. cardiology clinic) or multiple (e.g., geriatrics clinic)6068. Patients could choose to have follow up with the geriatrician3159 and/or be connected with a primary care provider41. Clinics have developed guidelines and policies to guide the operation of services3168.
iii) Implementation of Evidence-Based Screening
All articles described the incorporation of gold-standard, evidence-based screening practices into their geriatric care. Mood symptoms were assessed using the Hospital Anxiety and Depression Scale60626367, the Geriatric Depression Scale 6263, the Older Peoples’ Quality of Life Questionnaire67 and/or the Patient Health Questionnaire39, while cognition was assessed using tools such as the Montreal Cognitive Assessment60. CGAs were followed up with direct actions such as counseling (e.g., about ageing) 313960, assessments of comorbidities, age-appropriate preventative health screening416061, and pharmacist reviews targeting polypharmacy and drug safety4160. In addition to the CGA, clinics offered British HIV Association (BHIVA)-recommended screening (i.e., guidelines for the management of HIV), an antiretroviral review, a functional review and full medication review3166. Emotional support was monitored using the ‘Therapy Content Checklist’6263. The goal of using valid measurements was to promote best practice 5968.
Model Component 3: Pillars of Holistic Care
As older persons are more likely to experience cumulative health challenges that affect their quality of life, models of care for people ageing with HIV have incorporated a comprehensive holistic management approach. All included articles adhered and contributed to this model component. Clinics provided care for patients with multimorbidity60 61 66 67 and helped them to overcome socioeconomic challenges41 59 65, substance use disorders 60 65 and social isolation60 62 63 by understanding their backgrounds41. Physical health consultations considered cardiovascular disease, dental health, eye health and bone health31 41 60 61 64 68 to address HIV and metabolic-related complications41. Care plans incorporated medication prescriptions31 39 60 61 66–68, preventative screening31 39 60 61 64–68, age-related disease processes (e.g., cognitive-testing)31 39 41 59–61 64–68, psychosocial interventions to improve social networks and mental health31 39 59 60 62–65, exercise and nutrition regimens 39 41 59–61 64–66 and behavioural health supports (e.g., smoking cessation, therapy)31 39 59–64 67 to meet the holistic needs of each patient. Spiritual support delivered through religious leaders, mental health counselors/therapists, and emotional support volunteers was also offered59 64.
i) Comprehensive Geriatric Assessment
Most models of care (n = 8/13,61.5%) involved a CGA31 39 41 60 61 66 68 or utilized geriatric screening tools65 to guide holistic care plans. Most CGAs were delivered by geriatricians who would write full consultation notes39 60 61, although non-geriatrician health care providers were often trained to administer geriatric screening tests41 64. The CGA provided an overview of physical and mental health, as well as social support systems39, using validated scales39.
ii) Supporting Self-Management
The models of care in six articles (n = 6/13, 46%) aimed to support the self-management of older adults living with HIV. The goal of self-management was to enable patients to better manage their health outside of the clinic setting by involving older adults in medical decision-making60 68 and managing their chronic illnesses59–61. Self-management involved education39 59 60 65 and coaching31 about health behaviours, guidance for choosing appropriate interventions39 59 65 to improve a patient’s health status31 65, and increased health care utilization to improve patient involvement in care60 65. Some models involved classes where older adults could learn about various health conditions60–63. Where self-management was not possible due to cognitive or functional impairments, healthcare professionals provided education to individuals’ social support networks such as to encourage their inclusion in care39 59. To evaluate self-management, some studies included surveys about knowledge in the evaluations of the clinic models60 61.