HIV As a Comorbidity
People Living with HIV (PLWHIV) can now enjoy extended lifespans and may live with HIV as a comorbidity and not die from AIDS and its opportunistic infections, as was once common with an AIDS diagnosis. Because of this dramatic shift in HIV disease over the past two decades, this afternoon I had the privilege of attending a home wedding between two of our clients.
This particular wedding was especially notable by the fact that it was between two men who have been a couple for twenty-eight years. Both men are HIV-positive and one is on hospice care. This wedding was the first same sex wedding that our AIDS Service Organization (ASO) in Central Texas has experienced between two clients since marriage equality went into effect on June 26, 2015. The hospice chaplain officiated the ceremony and the witnesses were the hospice social worker, two ASO Medical Case Managers, the ASO Patient Navigator, and myself, their RN Medical Case Manager. This wedding was a joint effort between the hospice agency and the ASO and took many months to bring to fruition. Why so long? There were so many barriers that first needed to be overcome: social, economic, legal, and physical; and we, as an interdisciplinary team from both organizations, were able to overcome the roadblocks and facilitate this long overdue life cycle event.
I have witnessed this dramatic change in the lives of PLWHIV over the past two decades. An HIVAIDS diagnosis is seldom a hospice primary diagnosis, as it once was. Because of this shift, I look forward to attending many more life cycle events, with our HIV-infected clients, as they live longer with HIV and approach old age; life cycle events that, decades ago, HIV-infected individuals never dreamed they would live long enough to enjoy.
In my current role as RN Medical Case Manager at AIDS Services of Austin, Inc. (www.asaustin.org), I work with HIV-infected individuals, supporting them in HIV medication adherence and retention in HIV primary care. These two simple goals of medication adherence and retention in care can transform HIV/AIDS from a potential death sentence (as we commonly experienced in the 1980s-mid 1990s) to a chronically managed disease. With daily HIV medication adherence, the HIV viral load can become suppressed to less than 20 copies/mL, allowing the CD4 T-cell count to rise above 200mm3, potentially preventing the development of the opportunistic infections (mycobacterium avium complex, pneumocystis pneumonia, cryptosporidium, and toxoplasmosis to name a few) that were so common early on in the AIDS epidemic. The year 2015 marked the first time that there were more individuals aged 50 and older living with HIV than individuals under 50 years old. Consequently, we, as hospice and palliative care clinicians, will be experiencing an increasing number of hospice and palliative care patients who will have HIV as a comorbidity, rather than as the hospice primary diagnosis.
Circling back to the wedding couple and looking at their comorbidities in reference to HIV and aging, one partner (age 55) was HIV-positive, diabetic, hypertensive, and reports chronic pain and neuropathy; the other partner (age 62), who is currently on hospice, is HIV-positive, diabetic, has cardiomyopathy, and is post stroke. The hospice partner was admitted to services under a heart disease diagnosis: no longer a candidate for surgical procedures and has an ejection fraction of 20%. Because he has been on HIV antiretroviral therapy (ART), he is virally suppressed and consequently does not present with any of the listed guidelines under a HIV primary diagnosis.
Because of HIV medication adherence, retention in medical care, and the highly effective new cocktails of HIV medications, I have witnessed this dramatic change in the lives of PLWHIV over the past two decades. An HIVAIDS diagnosis is seldom a hospice primary diagnosis, as it once was. Because of this shift, I look forward to attending many more life cycle events, with our HIV-infected clients, as they live longer with HIV and approach old age; life cycle events that, decades ago, HIV-infected individuals never dreamed they would live long enough to enjoy. hospital’s Intensive Care Unit (ICU) for treatments, none of which would be effective. Now transferred from the ICU to the PCU, the four of us were having this end-of-life care decision conversation.