Comprehensive Care for Older Adults With HIV

geriatric patient and doctor smiling at one another

Improved treatment for HIV means that adults with the disease are living longer. Both living with HIV and caring for older adults with HIV can be a challenge. Older adults with HIV often need help with mobility, memory, and managing their medications. Research shows that they can benefit from a geriatric-centered approach and from having a community health worker involved in their care. 

Mount Sinai’s Brookdale Department of Geriatrics and Palliative Medicine has partnered with the Institute for Advanced Medicine at the Mount Sinai Health System to deliver the Comprehensive Care for Older Adults with HIV. This program uses a team approach to meet the myriad needs of older adults with HIV. The team includes a geriatrician, a registered nurse, a pharmacist, a social worker, and a community health worker (CHW). The model’s major innovation is the CHW, who serves as the patient’s navigator, supporter, and educator.

We strive to improve care for older adults with HIV by: 

  • Providing age appropriate patient-centered care.
  • Enhancing our efficiency and teamwork.
  • Understanding and aligning patient goals with their treatment.
  • Reducing the number of missed appointments.
  • Improving patient adherence and healthcare access.

This demonstration program is located at the Institute for Advanced Medicine’s Peter Krueger Clinic in New York City. Our goal is to stimulate the creation of additional programs in New York City and other U.S. locations.

Program Overview

The Need

Thanks to advancements in HIV treatment, the population of older people living with HIV is increasing. By 2030, the U.S. National Institutes of Health estimates that about 70 percent of those with HIV in the United States will be over age 50. That’s roughly half a million Americans. Older adults with HIV tend to have more complex needs, additional medical conditions and psychosocial challenges, such as elevated rates of depression, anxiety, loneliness, and social isolation compared to older adults without HIV. They may also struggle more with obtaining food and housing than most people over age 50. As a result, many older people with HIV have worse health outcomes and a lower quality of life than their peers. Our Comprehensive Care for Older Adults With HIV program aims to help.

Our Approach: The Six Ms

The program is based on the six Ms of geriatric-HIV care, which are generally accepted as priority areas for older adults. These principles emphasize avoiding harm, using evidence-based practices, and meeting the individual needs of the patient and family. The Ms are:

  1. Mind: Maintaining mental abilities; preventing, treating, and managing dementia; and evaluating and treating depression
  2. Mobility: Preserving the ability to walk and maintain balance and preventing falls and other injuries
  3. Medication: Streamlining medications so patients take only the drugs they need, and building awareness of and reducing any drug side effects
  4. Multi-complexity: Helping patients manage multiple health conditions, especially when these are affected by their age and social concerns
  5. Matters most: Emphasizing the patient’s care goals, the outcomes they want, and their care preferences; helping plan for the future through advanced directives
  6. Modifiable issues: Focusing on issues (such as diet and exercise) that can be improved for overall healthy aging

Patients are referred to the program for a variety of reasons, including:

  • Cognitive concerns
  • Mobility issues
  • Complex medication needs (typically five or more prescriptions)
  • Care goal discussions

Community Health Workers

Community health workers play an important role on the health care team. They serve as a bridge between the health care system and the patient and caregivers to help identify and access necessary services within the Health System and the community. In addition, community health workers:

  • Help set up and organize health care visits
  • Perform some health care screenings and other assessments
  • Assist in coordinating personal treatment plans
  • Support patients and caregivers within the clinic and community organizations
  • Navigate and coordinate referrals for patients and caregivers to clinical, supportive, and community-based services

Meet Our Team Leadership

Our team includes researchers and health care providers. They work together to provide the best possible treatment for older adults living with HIV.

  • Abigail Baim-Lance, PhD, Associate Professor, Geriatrics and Palliative Medicine, and Demonstration Project Administrator/Evaluator
  • Angela Condo, MD, Assistant Professor, Geriatrics and Palliative Medicine, and Demonstration Project Clinical Director
  • Fred Ko, MD, Associate Professor, Geriatrics and Palliative Medicine, and Medicine (Hospital Medicine), and Demonstration Project Administrator/Evaluator
  • Christian Espino, Program Manager II, Geriatrics and Palliative Medicine, and Demonstration Project Clinical Manager

Funding

Comprehensive Care for Older Adults With HIV receives funding from a variety of sources, including the Keith Haring Foundation (since 2020) and the U.S. Health Resources and Services Administration (2022-2025).

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