Treatment of HIV/AIDS in the nursing home: variations in rural and urban long-term care settings.

Objectives: With the increased use of antiretroviral therapy, more patients with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) are surviving for long periods of time. The aim of this study was to determine the availability of specialty HIV/AIDS services in long-term care facilities, and to determine differences in the availability of these services between rural and urban nursing homes.

Methods: 1,423 nursing homes from the 1999 National Nursing Home Survey were stratified by rural/urban status and compared using [chi square] analysis and logistic regression.

Results: Less than 1% of surveyed nursing homes in the United States provided specialty HIV/AIDS services. While there was evidence that larger nursing homes are more likely to provide HIV/AIDS-related services, there were no significant differences between rural and urban nursing homes in the provision of specialty HIV/AIDS services.

Conclusions: A vast majority of nursing homes in the United States do not provide any specialty areas for HIV/AIDS care. As our population ages and the life span of those diagnosed with HIV/AIDS continues to increase, nursing homes will begin to see patients diagnosed with HIV/AIDS among those seeking care.

Key Words: acquired immunodeficiency syndrome (AIDS), highly active antiretroviral therapy (HAART), human immunodeficiency virus (HIV), long-term care.

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With new anti-retroviral treatments, human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) can now be viewed as a chronic illness, and patients infected with this disease can be expected to have increased life expectancies and decreased morbidity. (1,2) Increased life expectancies among those with HIV/AIDS will result in older people requiring treatment for HIV/AIDS. As people age, they become more likely to require long-term care services.

Since the emergence of HIV/AIDS in the United States, the number of Americans diagnosed with the disease is still increasing. As of 2001, the Centers for Disease Control and Prevention reported over 300,000 cases of AIDS, with an additional 161,976 cases of HIV in the United States. (3) It has also been noted that an increasing proportion of older Americans are being diagnosed with HIV. (4) The increased prevalence of AIDS and HIV, coupled with the increasing numbers of elderly in our country, will create a situation in which long-term care facilities will be required to treat and handle patients with HIV and AIDS.

The increasing population of AIDS patients who are expected to need long-term care services is a growing concern to nursing home providers. (5) A survey by the Catholic Health Association in 1992 stated that a major concern of its affiliated long-term care facilities is how to deal with the rising number of AIDS patients it treats. (6) Furthermore, the increased prevalence and spread of AIDS will result in a larger number of people in rural communities being affected by the disease. Those with HIV or AIDS requiring care in rural areas are steadily increasing in number, (7) while the ability to provide services to these individuals in their rural setting is limited. (8) In 1999, the proportion of adults with AIDS was highest in the rural South compared with other nonmetropolitan regions throughout the country. (9) Therefore, there is a need for long-term care of AIDS patients in rural communities.

This study examined the facility resources available for treating HIV/AIDS patients in long-term care settings. Furthermore, this study determined whether differences in the availability of care exist for rural HIV/AIDS patients compared with those living in urban areas.

Materials and Methods

Study data was drawn from the facility portion of the 1999 National Nursing Home Survey (NNHS), a nationally representative survey that used a stratified, two-stage probability design. The total estimated number of nursing homes in this survey was 18,000.

The primary sampling strata of this data included facility characteristics such as the number of beds and certification status. The data was then further stratified by the following characteristics: hospital-based versus nonhospital-based; ownership status; geographic region; whether the nursing home was in a metropolitan statistical area (MSA); state; county and zip code. Facilities were then selected using a systematic sampling approach in which the probability of being chosen for the survey was proportional to a facility's number of beds. (10)

Analyses for this study were conducted at the Research Data Center of the National Center for Health Statistics (NCHS) in Hyattsville, MD, due to the restricted nature of the data. Public use files did not contain certain weighting variables and variables necessary to calculate standard errors. All analyses were conducted in SUDAAN (Research Triangle Institute, Research Triangle Park, NC) to account for the complex sampling design of the survey.

Both bi-variate and multi-variate methods were used to analyze the data. The main dependent variable in this study was the dichotomous variable indicating the presence of a specific area in the long-term care facility for HIV/AIDS care. The main independent variable was Metropolitan Statistical Area (MSA) status, which was a proxy for rural/urban status. Being in an MSA for this survey was defined as being in a county or group of counties that contain at least one city and have a population of at least 50,000 people, including adjacent counties that are metropolitan in nature and are integrated into the central city. Other independent variables were used for both stratification of the data and to control for variance in regression models.

The presence of areas for HIV/AIDS treatment services within the long-term care facility was compared with the long-term care facility's MSA status using [chi square] tests. Other stratifying variables were compared with the dependent variable in the same manner using [chi square] tests.

Finally, a logistic regression model was used to test for the independent effects of rural location of the long-term care facility on the presence of specialty HIV/AIDS service areas, after adjusting for potential confounders. Variables including number of beds, ownership of facility, and membership of a chain or group were included in the logistic regression model as controlling variables.

Results

Overall, only 0.7% of facilities surveyed provided specialty HIV/AIDS treatment. Some notable differences were found between long-term care facilities located in rural and urban areas (Table 1). Rural long-term care facilities were more likely to be smaller and to have a greater dependence on patients funded only by Medicaid. When we looked at HIV/AIDS services, though, no difference was noted between the long-term care facilities located in urban and rural areas (P = 0.67).

To determine whether the differences in long-term care facility size or payer mix might have obscured differences in the offering of specialty HIV/AIDS programs between the urban and rural long-term care facilities, we performed a logistic regression including ownership status, membership of a chain or group, and number of beds, along with rural/urban status in the model. Medicare and Medicaid certification was not included in the regression model due to overall small sample sizes for facilities that did offer HIV/AIDS specialty services. The model showed that facilities with a smaller number of beds were significantly less likely to offer specialty HIV/AIDS services, but that no relationship existed between rural and urban long-term care facility location and HIV/AIDS services, even after adjusting for potential confounders (Table 2).

Discussion

The major finding of this study is that only a small number of long-term care facilities currently offer a specialized area for HIV/AIDS services. Less than 1% of both urban and rural nursing homes indicated that they offered specialty HIV/AIDS care. Larger nursing homes were more likely to provide HIV/AIDS specialty services, but no other variables, including location of the nursing home inside or outside an MSA, were associated with the availability of specialty HIV/AIDS services.

The currently small percentage of nursing homes that provide specialty HIV/AIDS services could possibly be explained by the lack of any financial incentive for the facility to provide these types of units. Overhead costs for providing a specialty unit may outweigh financial benefits.

In addition, nursing homes may not see a need for developing specialty services in this area. Elderly persons with HIV/AIDS already may be receiving special care in community settings such as home care or in specialty centers, rather than in traditional institutional settings. Several demonstration projects that are supporting the development of community-based programs for HIV/AIDS patients have been studied recently. (11) These projects are targeted at Medicaid-eligible populations with AIDS, and focus on reducing hospitalizations and mortality through comprehensive primary care delivery systems funded with risk-adjusted Medicaid premiums.

Not surprisingly, smaller long-term care facilities were significantly less likely to offer specialized HIV/AIDS services. Also, it was demonstrated that a larger proportion of facilities with smaller numbers of beds were located in rural areas. Our data indicate that there is currently no difference between rural and urban nursing homes in the availability of HIV/AIDS-related services. However, if larger nursing homes continue to expand their services to include HIV programs, disparities in the availability of HIV care may develop in the future. Two of the most notable of these programs based in larger nursing homes are the AIDS Health Care Foundation of Los Angeles and the Johns Hopkins AIDS Care Program in Baltimore. (11)

Even with other treatment options available for those suffering from HIV/AIDS, there will still be a need for long-term care services among older people who could potentially also be diagnosed with HIV/AIDS. One study by Selwyn et al (12) described the patients admitted to a skilled nursing facility in New Haven, CT. The average age of the admitted patient was 41 years. Fifty-two percent of those patients had impairments in at least one "activity of daily living." These patients were taking a median of 11 medications. More than 80% of the patients were taking some form of anti-retroviral, anti-bacterial, or anti-fungal therapy.

Another study using a retrospective case-control design suggested that patients diagnosed with HIV and older than 55 years of age scored significantly higher on the Charlson comorbidity index than a cohort of those under 45 years of age. (13) With increased medication regimens and increased levels of comorbidity, these patients present a high level of acuity that will require potentially more technical care than some nursing homes are accustomed to providing.

Functional and cognitive impairments associated with old age may be the reason a person initially seeks long-term care services. Those reasons could, however, be complicated with an HIV/AIDS diagnosis as well. It has also been suggested in one study (14) that treatment with protease inhibitor-based highly active anti-retroviral therapy (HAART) increased the likelihood of significant bone demineralization, thereby increasing the prevalence of osteopenia and osteoporosis in persons living with HIV/AIDS. This problem could be complicated with age-related bone loss, resulting in increased hospitalizations and nursing home placement for bone fractures. In light of these concerns, long-term care facilities that are not accustomed to caring for patients with HIV/AIDS should begin preparing for those potential patients that require more technical care.

Several limitations in this study should be noted. The first limitation is that it is possible that the nursing homes in this study provide treatment to HIV/AIDS patients but do not offer a specialty treatment area. The facility portion of the National Nursing Home Survey did not determine whether HIV/AIDS patients were being treated within the nursing home. Therefore, these patients may have been receiving care within the nursing home, but no specialty area for this care was provided.

Secondly, because of the low number of facilities offering specialty AIDS services, no real differences could be seen between urban and rural facilities. A larger sample of facilities offering HIV/AIDS services may have provided a statistically significant difference between those in rural areas and those in urban areas.

Future work in this area would include performing prospective data collection wherein facilities are surveyed on whether or not they accept HIV/AIDS patients. Also, this work would include studies to determine how these patients are treated while in the facility.

Past research has explored the willingness of nursing homes to provide care to those diagnosed with HIV/AIDS. (15-17) However, much of this research was conducted in the early stages of the disease's emergence, before more effective treatments were developed, and did not look specifically in rural communities. Therefore, future studies could focus on the present attitudes of long-term care providers in rural areas in delivering care to those infected with the disease, now that a decade has passed since these earlier studies and more is known about the disease.

Ethical dilemmas arising from the treatment of patients with HIV/AIDS will be another area that should be researched. Allocation of resources for these patients will be an issue that will be debated. (18) The stigma related with the disease affects the seeking of care. (19) Therefore, the distribution and delivery of services for HIV/AIDS patients in rural areas should be investigated.

Conclusion

This study indicates that large numbers of nursing homes are not providing specialty areas for the treatment of HIV/AIDS. As the life spans of people diagnosed with HIV/AIDS continue to increase and our nation's population ages, the prevalence of the disease will continue to grow among older people. As these people begin to require care for traditional reasons in long-term care settings, the long-term care industry will be required to deal with the comorbidity of HIV/AIDS among its populations. Will providers, families of patients, and current residents of nursing homes be willing to deal with HIV/AIDS in their facilities? Will the supply of beds be adequate to meet the demand for this population of people? How should this population be treated with their special needs? These are questions that need to be addressed and researched in more depth to help prevent disparities in care and improve quality.

Table 1. Comparison of urban and rural long-term care facilities
(n = 1423)

                   Urban (a)      Rural     P

AIDS service
area provided                               0.67
  Yes                0.6%           0.8%
  No                99.4%          99.2%
Ownership of
facility                                    0.11
 For profit         68.5%          63.5%
 Other              31.5%          36.5%
Membership of a
chain/group                                 0.59
 Yes                60.8%          59.1%
 No                 39.2%          40.9%
Number of beds                             <0.01
  3-49              10.6%          13.1%
  50-99             30.1%          52.2%
  100-199           47.6%          32.6%
  200+              11.7%           2.1%
Medicare/Medicaid
certification                              <0.01
 Medicare &
 Medicaid           83.8%          78.6%
 Medicare only       4.3%           2.4%
 Medicaid only       8.4%          17.5%
 Others              3.6%           1.5%

(a) All percentages are weighted, national estimates.

Table 2. Logistic Regression Determining the Likelihood of Offering
Specialty HIV/AIDS Service Areas (n = 1423)

                        [beta]  SE [beta]   OR       95% CI

MSA status
 Urban                   0.00      0.00     1.00    1.00-1.00
 Rural                   0.70      0.62     2.01    0.60-6.74
Ownership of facility
 For profit              0.00      0.00     1.00    1.00-1.00
 Others                  0.61      0.48     1.84    0.72-4.70
Membership of a chain/
group
 Yes                     0.00      0.00     1.00    1.00-1.00
 No                     -0.04      0.49     0.96    0.36-2.51
Number of beds
 101+                    0.00      0.00     1.00    1.00-1.00
 3-100                  -2.18      1.07     0.11    0.01-0.91

Accepted October 22, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9704-0338

Please see James K. Schmitt and Charles P. Stuckey's editorial on page 329 of this issue.

References

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10. Jones A. The National Nursing Home Survey: 1999 summary. National Center for Health Statistics. Vital Health Statistics 2002;13(152).

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12. Selwyn PA, Goulet JL. Molde S, et al. HIV as a Chronic Disease: Implications for Long-Term Care At an AIDS Dedicated Skilled Nursing Facility. J Urban Health 2000;77(2):187-203.

13. Skiest DJ, Rubinstein E, Carley N, et al. The Importance of Comorbidity in HIV-infected Patients over 55: A Retrospective Case-Control Study. Am J Med 1996;(101):605-611.

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RELATED ARTICLE: Key Points

* The use of highly active antiretroviral therapy (HAART) is contributing to an increase in the prevalence of HIV/AIDS in older populations.

* Less than 1% of all nursing homes in the United States offer specialty HIV/AIDS services.

* There are no differences in the availability of specialty HIV/AIDS services between rural and urban long-term care facilities.

William S. Pearson, MHA, and William J. Hueston, MD

From the Department of Health Services Policy and Management, Norman J. Arnold School of Public Health, University of South Carolina, Columbia, SC, and the Department of Family Medicine, Medical University of South Carolina, Charleston, SC.

Reprint requests to William S. Pearson, MHA, Department of Health Services Policy and Management, Norman J. Arnold School of Public Health, University of South Carolina, Columbia, South Carolina 29208.