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Objectives: Advances in antiretroviral therapy have meant that the focus of HIV care has shifted to chronic disease management. The HIV population is ageing, and the prevalence of frailty is increasing. This study aimed to explore the perspectives and experiences of the impact of living with HIV and frailty and priority outcomes in relation to wellbeing and ageing., Methods: In-depth qualitative interviews were undertaken with older people living with HIV who screened positive for frailty using the FRAIL scale. Participants were recruited from a UK outpatient HIV clinic. Interviews were analysed using reflexive thematic analysis., Results: In total, 24 people living with HIV were interviewed. Frailty was described as not being able to do the things you could and living with limitations that impacted physical, psychological and social wellbeing. Being identified as frail was not always surprising, but acceptance of this diagnosis required an understanding of what frailty means and what they can do to address it. For people living with HIV, the word 'frail' was largely acceptable when its clinical meaning was explained. However, participants questioned whether a different term is needed if this is a new 'HIV-associated frailty'. Priority outcomes were slowing the progression of frailty, retaining independence and being treated holistically., Conclusion: When talking about frailty with people living with HIV, professionals need to balance honesty and sensitivity and provide clear information about the meaning and impact for the person. Holistic management plans must recognize the physical and psycho-social impact of frailty and prioritize slowing its progression and reducing its impact on independence., (© 2024 The Author(s). HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Introduction: Diabetes is widely reported to be more common in people living with HIV (PLWH). Much of the data supporting this originated during the earlier HIV era. The perceived increased risk of type 2 diabetes is reflected in HIV clinical guidelines that recommend screening for diabetes in PLWH on anti-retroviral therapy (ART). However, international HIV clinical guidelines do not agree on the best marker of glycaemia to screen for diabetes. This stems from studies that suggest HbA1c underestimates glycaemia in PLWH., Methods: Within this review we summarise the literature surrounding the association of HIV and type 2 diabetes and how this has changed over time. We also present the evidence on HbA1c discrepancy in PLWH., Conclusion: We suggest there is no basis to any international guidelines to restrict HbA1c based on HIV serostatus. We recommend, using the current evidence, that PLWH should be screened annually for diabetes in keeping with country specific guidance. Finally, we suggest future work to elucidate phenotype and natural history of type 2 diabetes in PLWH across all populations., (© 2023 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Objectives: To evaluate the implementation of frailty screening in people living with HIV (PLWH) in a large urban cohort of patients in Brighton, UK., Methods: Focus group discussions with HIV professionals and PLWH interviews helped inform the design and implementation of the frailty screening pathway in the clinic. Data were collected from PLWH aged over 60 years attending their HIV annual health check from July 2021 to January 2023 (n = 590), who were screened for frailty by nurses using the FRAIL scale. We assessed the proportions of PLWH who screened as frail, prefrail or robust and compared patient characteristics across groups. All PLWH identified as frail were offered a comprehensive geriatric assessment delivered by a combined HIV geriatric clinic, and uptake was recorded., Results: A total of 456/590 (77.3%) PLWH aged over 60 years were screened for frailty. Median age and time since HIV diagnosis (range) for those screened were 66 (60-99) years and 21 (0-32) years, respectively. In total, 56 (12.1%) of those screened were identified as frail, 118 (25.9%) as prefrail and 282 (61.8%) as robust. A total of 10/56 (18%) people identified as frail declined an appointment in the geriatric clinic. Compared with non-frail individuals, frail PLWH had been living with HIV for longer and had a greater number of comorbidities and comedications but were not chronologically older., Conclusions: Implementing frailty screening in PLWH over 60 years old is feasible in a large cohort of PLWH, as recommended by the European AIDS Clinical Society. More research is needed to determine if frailty screening can improve clinical outcomes of older PLWH and the use of the comprehensive geriatric assessment within HIV services., (© 2023 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Background: The Optimal Care Pathways (OCP) are a framework to promote high-quality and integrated cancer care for all Australians, from prevention through to end-of-life-care. Aboriginal and Torres Strait Islander people experience disproportionate cancer incidence and mortality, but little research has addressed whether cancer care for Aboriginal people meets the standards prescribed by the OCPs. This study aims to consider barriers and facilitators to quality cancer care for Aboriginal people., Methods: Semi-structured interviews were conducted with 30 health professionals who deliver care to Aboriginal people with cancer in primary care and hospital settings in New South Wales, Australia. Health professionals included Aboriginal Health Workers, nurses, general practitioners, and community workers. Interviews were conducted in 2019-2020 and explored participant perspectives of barriers and facilitators of optimal cancer care, particularly related to prevention, early detection, diagnosis, and treatment for Aboriginal people. Data were qualitatively analysed using framework analysis., Results: In general, participants perceived Aboriginal patients to have good access to preventive care. In terms of early detection and diagnosis, access to primary care, pathology, radiology, and some specialists (e.g. respiratory physicians) was seen as optimal. However, access to hospital-based gastroenterologists for colonoscopy was perceived to be poor due to long wait times. Access to optimal care for cancer treatment was perceived to be hindered due to the lack of bulk-billing for bowel cancer, breast cancer, and cardiothoracic surgery. Other barriers to care identified by participants included unclear referral pathways, poor communication between patient and the treating team, and a lack of timely provision of discharge summaries., Conclusions: Facilitators of optimal care during treatment and survivorship included: the Integrated Team Care and Close the Gap programs, and presence of key health workers to help patients navigate the health system. The major barriers to quality cancer care for Aboriginal people appeared to be to specialist and procedural access, demonstrating that the 'Inverse Care' law applied in reducing access for populations at higher risk of cancer.

Objectives: People with HIV are an ageing population with an increased risk of cognitive impairment. Although cognitive impairment is dependent upon assessment, the acceptability of screening for cognitive impairment is unclear. This study aimed to explore the views of people with HIV and healthcare workers regarding routine screening for cognitive impairment., Methods: In-depth individual qualitative interviews were conducted with purposively sampled people with HIV and focus groups of healthcare workers from a UK HIV service. Verbatim pseudonymized transcripts were analysed using reflexive thematic analysis supported by NVivo., Results: Twenty people with HIV were interviewed and 12 healthcare workers participated in three focus groups. People with HIV were concerned about developing cognitive issues and were receptive to routine screening. Screening was seen as relevant and an important part of managing health in older age. Healthcare workers expressed concerns regarding the capacity of HIV services to implement routine screening and questioned the validity of screening measures used. People with HIV felt that screening and subsequent detection of cognitive impairment, if present, may help them to prepare for future issues and promote active management strategies and care pathways that would support cognitive health. People with HIV felt that screening should be brief and delivered by the HIV service and that they should be given a choice of administration method. Indications of cognitive impairment detected by a brief screening assessment should be discussed face to face and followed up with a comprehensive assessment., Conclusions: People with HIV are concerned about cognitive impairment and would welcome regular screening for this as part of the holistic care provided by the HIV team. Both people with HIV and healthcare workers would like more information on cognitive impairment, its screening and ways to support cognitive health., (© 2023 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

(1) Background: Aboriginal women have a higher mortality from cervical cancer, yet cervical screening rates are lower than for other Australian women. (2) Methods: A randomised controlled trial of reminder letter vs. phone call/SMS for routine cervical screening testing in an Aboriginal Community Controlled Health Organisation in NSW. (3) Results: 256 women aged between 25 and 74 who were due for cervical screening were randomised to receive a reminder letter (and up to two further letters for non-responders) or a phone call (followed by up to two SMS) to attend the screening. A total of 15 women (12.5%) attended for cervical screening test within 3 months following a letter, and 24 women (17.6%) after a phone call/SMS reminder; this difference was not significant ( p = 0.252). Time spent on sending letters vs. phone calls/SMS was similar; the cost was lowest for SMS. (4) Conclusion: Response to reminders was lower than expected. While there was no significant difference in effectiveness in letter vs. phone call/SMS for cervical screening recalls, reminder systems, including opportunistic reminders, can play a role in encouraging women to participate in screening programs in conjunction with national screening registers. The choice of reminder type should be left to service and consumer preference.

Introduction: Many people ageing with HIV are also living with multiple comorbidities and geriatric syndromes including frailty and cognitive deterioration. These complex needs can be challenging to meet within existing HIV care services. This study investigates the acceptability and feasibility of screening for frailty and of using a comprehensive geriatric assessment approach, delivered via the Silver Clinic, to support people living with HIV affected by frailty., Methods and Analysis: Mixed-methods, parallel-group, randomised, controlled feasibility trial aiming to recruit 84 people living with HIV≥50, identified as frail. Participants will be recruited from the HIV unit at the Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK. Participants will be randomised 1:1 to receive usual HIV care or the Silver Clinic intervention, which uses a comprehensive geriatric assessment approach. Psychosocial, physical and service use outcomes will be measured at baseline, 26 weeks and 52 weeks. Qualitative interviews will be conducted with a subset of participants from both arms. Primary outcome measures include recruitment and retention rates and completion of clinical outcome measures. These will be used in conjunction with a priori progression criteria and the qualitative data (acceptability of trial procedures and intervention) to determine the feasibility and design of a definitive trial., Ethics and Dissemination: This study has been approved by East Midlands-Leicester Central Research Ethics Committee (reference 21/EM/0200). All participants will receive written information about the study and be required to provide informed consent. Results will be disseminated via peer-reviewed journals, conferences and community engagement., Trial Registration Number: ISRCTN14646435., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: People living with HIV are an ageing population with an increasing prevalence of frailty. Management of frailty requires assessment, communication and information sharing with patients. However, evidence regarding the meaning of frailty for this population, and the acceptability of frailty screening, is limited. This study aimed to explore the perceptions of older people living with HIV and HIV professionals towards frailty and routine screening for frailty., Methods: Data collection consisted of in-depth individual qualitative interviews with older people living with HIV and focus groups with HIV professionals purposively sampled from outpatient HIV clinics in London and Brighton, UK. Verbatim pseudonymised transcripts were analysed using reflexive thematic analysis supported by NVivo., Results: A total of 45 people living with HIV were interviewed, and 12 HIV professionals participated in two focus groups. Frailty was described as a series of losses around mobility, social inclusion, independence and mental acuity, which could happen at any age. Regarding language, for people living with HIV, explicitly using the word frail was acceptable during screening when approached sensitively and alongside provision of information and support to slow the progression of frailty. However, HIV professionals described concerns about using the word frail for fear of causing distress or offence., Conclusion: Professionals described frailty in terms of functional deficits, whereas people living with HIV described a loss of personhood. Although there is a clear desire among people living with HIV to be informed of their frailty status, approaching conversations about frailty with understanding and compassion is vital. To gain the most from the screening, it is essential that frailty status is shared alongside a clear plan of actionable steps in their care., (© 2022 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Objectives: To evaluate HIV testing of patients aged ≥50 years presenting to secondary care with clinical indicator conditions (CICs) for HIV., Methods: Retrospective audit of electronic records for patients aged ≥50 years discharged from hospital between January 1st and July 31st 2019 who had at least one documented CIC. Patient demographics and HIV testing data were collected from clinical systems (excluding sexual health databases)., Results: 2478 patients with a CIC were identified. 222 (9.0%) received an HIV test within 31 days of discharge. Patients receiving a test were significantly younger (mean 68.6 versus 75.3 years; P < 0.001) and significantly more men underwent testing than women (60.4% versus 39.6%; P = 0.001). 32 CICs were identified across nine disease systems. By system, those with a haematological CIC were significantly more likely to undergo testing compared with all other CICs combined (P < 0.001). Of individual CICs, patients with Kaposi's sarcoma, hepatitis C, neutropenia, lymphadenopathy, pyrexia of unknown origin and thrombocytopenia (P < 0.001), and seborrhoeic dermatitis, hepatitis B, other unexplained blood dyscrasia, and non-Hodgkin's lymphoma (P < 0.05) were more likely to undergo testing than those presenting with other CICs. Patients with dementia and lung cancer were less likely to undergo testing (P < 0.001). Patients presenting with a greater number of CICs were significantly more likely to undergo testing (P = 0.002)., Conclusions: HIV testing among patients aged ≥50 years presenting to secondary care with a CIC is low. Work is needed to improve HIV testing practice in this patient group., (© 2022 British HIV Association.)

Background: Many medical students may encounter a range of academic and personal challenges during their course of study, but very little is known about their experiences. Our aim was to review the literature to inform future scholarship and to inform policy change., Methods: A scoping review was conducted searching PubMed, MEDLINE, EMBASE, PsycInfo, British Education Index, Web of Science and ERIC for English language primary research with no date limits. This retrieved 822 papers of which eight met the requirements for inclusion in the review. Data were independently reviewed by two researchers and underwent thematic analysis by the research team., Results: Three major themes emerged. Theme 1: 'Identity preservation' addressed students' aim to preserve their sense of self in the face of academic difficulty and their tendency to seek support. This connected the apprehension many students expressed about their educational institutions to Theme 2: 'The dual role of the medical school'-medical schools are required to support struggling students but are predominantly seen as a punitive structure acting as the gatekeeper to a successful career in medicine. Students' apprehension and attempts to protect their identities within this complex landscape often resulted in 'maladaptive coping strategies' (Theme 3)., Conclusion: Understanding and exploring the academic challenges faced by medical students through their own experiences highlight the need for the development of more individualised remediation strategies. Educators may need to do more to bridge the gap between students and institutions. There is a need to build trust and to work with students to enhance their sense of self and remediate approaches to engagement with learning, rather than focusing efforts on success in assessments and progression., (© 2021 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Purpose of Review: The HIV population is ageing with rising rates of frailty though strategies of how best to manage it remain ill-defined. It also remains unclear what the prevalence of frailty is within this cohort, how best to diagnose it and what factors are associated., Recent Findings: The prevalence of frailty remains unclear because of heterogenous results. Routine screening in those 50+ is recommended and whilst the Fried Frailty Phenotype is currently preferred the Clinical Frailty Scale could be considered. No biomarkers are currently recommended. Looking at associated factors, HIV neurocognitive impairment and long-term alcohol usage has been shown to be associated with developing frailty whilst those who are frail have been shown to be less active and more likely to fall. NAFLD with fibrosis has been shown to be an indicator of metabolic age and the Pooled Cohort Equations has been shown to be more effective in diagnosing cardiovascular risk in frail people living with HIV., Summary: Whilst the prevalence of frailty differs between countries, with the addition of prefrailty, this represents a large proportion of people living with HIV. Services must ensure strategies are in place to support those living with HIV and frailty. Further longitudinal studies are required., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Older persons and patients with frailty constitute an ever increasing proportion of hospital patients. Improving student attitudes towards both groups is important in preparing future doctors for this demographic shift. We aimed to investigate medical student attitudes towards older persons and frailty over an entire medical school cohort., Methods: All current Brighton and Sussex Medical School students were invited to complete an online questionnaire consisting: (i) the Australian Ageing Semantic Differential (AASD), (ii) the Medical Condition Regard Scale (MCRS) with regards to frailty, (iii) a qualitative question asking participants to record three words regarding both a person over 70 years and frailty., Results: 187 students participated (66% female, 25.2% response rate). Participants reported positive attitudes with mean scores of 73.45/114 on the AASD and 52.4/66 on the MCRS. The most positive attitudes towards both older persons and frailty were held by year 1 students, and most negative by year 3 and year 4 students for older persons and frailty, respectively. Examining AASD subgroups, students held negative attitudes towards the instrumentality (function) of older persons (mean score: 17.6/36) with significant variation across year groups (p < 0.05), with the most negative attitudes expressed in year 3. Word clouds of qualitative responses showed that medical students consider the two concepts differently with frailty attracting more negative associations., Conclusion: Generally medical student attitudes were positive towards older persons and frailty. However, these declined when focusing on the functionality, with word cloud analysis of attitudes revealing a dichotomy between the quantitative and qualitative data surrounding frailty.

Aims: HbA 1c is reported to underestimate glycaemia in people living with HIV (PLHIV). There is not an internationally agreed screening method for diabetes. The primary aim was to identify which tests are performed to diagnose and monitor diabetes in PLHIV. Secondary aims were to identify whether prevalence or incidence of diabetes differs according to marker of glycaemia and how figures compare in PLHIV compared to people without., Methods: Electronic databases were searched for studies investigating diabetes in PLHIV, not pregnant, aged ≥18 years. Narrative analysis and descriptive statistics were used to describe which markers of glycaemia, and their frequency, were employed in the diagnosis and monitoring of diabetes in PLHIV. Diagnostic studies provided prevalence or incidence of diabetes., Results: In all, 45 of 1028 studies were included. Oral glucose tolerance test (OGTT), fasting glucose (FG), HbA 1c and Fructosamine were used to investigate diabetes. In total, 27 studies described diagnosing diabetes, 14 using OGTT, 12 FG and 7 HbA1c. All 18 studies monitoring diabetes used HbA1c. Prevalence ranged from 1.3% to 26% and incidence 2.9% to 12.8%. Studies using glucose and HbA 1c reported HbA 1c to diagnose fewer people with diabetes, monitoring studies found HbA 1c to underestimate glycaemia levels. Controlled studies demonstrate diabetes was more common in PLHIV., Conclusion: OGTT was used most frequently to diagnose diabetes, and HbA 1c to monitor known diabetes. Prevalence and incidence varied depending on marker of glycaemia used. Studies reported a discrepancy in accuracy of HbA 1c in PLHIV, to address this, well-designed, prospective studies, providing individual-level data on HbA 1c levels and an additional marker of glycaemia in PLHIV are needed., (© 2020 Diabetes UK.)

Purpose: All UK medical schools are required to include frailty in their curriculum. The term is open to interpretation and associated with negative perceptions. Understanding and recognising frailty is a prerequisite for consideration of frailty in the treatment decision-making process across clinical specialities. The aim of this survey was to describe how frailty has been interpreted and approached in UK undergraduate medical education and provide examples of educational strategies employed., Methods: All UK medical schools were invited to complete an electronic survey. Schools described educational strategies used to teach and assess frailty and provided frailty-related learning outcomes. Learning Outcomes were grouped into categories and mapped to the domains of Outcomes for Graduates (knowledge, skills and values)., Results: 25/34 Medical schools (74%) participated. The interpretation of what frailty is vary widely and the diversity of teaching strategies reflect this. The most common Learning outcomes included as "Frailty" are about the concept of frailty, Comprehensive Geriatric Assessments and Roles of the MDT. Frailty teaching is predominantly opportunistic and occurred within geriatric medicine rotations in all medical schools. Assessments focus on frailty syndromes such as falls and delirium., Conclusion: There is variation regarding how frailty has been interpreted and approached by medical schools. Frailty is represented in an array of teaching and assessment methods, with a lack of constructive alignment to related learning outcomes. Consensus should be agreed as to what frailty means in medical education. Further research is required to explore which frailty-specific educational strategies in undergraduate medical education enhance learning.

As life expectancy in people living with HIV (PLWH) has increased, the focus of management has shifted to preventing and treating chronic illnesses, but few services exist for the assessment and management of these individuals. Here, we provide an initial description of a geriatric service for people living with HIV and present data from a service evaluation undertaken in the clinic. We conducted an evaluation of the first 52 patients seen in the clinic between 2016 and 2019. We present patient demographic data, assessment outcomes, diagnoses given, and interventions delivered to those seen in the clinic. The average age of attendees was 67. Primary reasons for referral to the clinic included management of complex comorbidities, polypharmacy, and suspected geriatric syndrome (falls, frailty, poor mobility, or cognitive decline). The median (range) number of comorbidities and comedications (non-antiretrovirals) was 7 (2-19) and 9 (1-15), respectively. All attendees had an undetectable viral load. Geriatric syndromes were observed in 26 (50%) patients reviewed in the clinic, with frailty and mental health disease being the most common syndromes. Interventions offered to patients included combination antiretroviral therapy modification, further health investigations, signposting to rehabilitation or social care services, and in-clinic advice. High levels of acceptability among patients and healthcare professionals were reported. The evaluation suggests that specialist geriatric HIV services might play a role in the management of older people with HIV with geriatric syndromes.

Objective: To evaluate the acceptability of a cancer care team based at an Australian Aboriginal medical service in supporting patients' cancer journeys and to assess improvements in access to cancer care., Design: The cancer care team consisted of an Australian Aboriginal health worker, counsellor and enrolled nurse employed for 2 days a week, supported by a general practitioner. The cancer care team supported patients from prediagnosis while investigations were being undertaken, at diagnosis and through treatment, such as surgery, chemotherapy and radiotherapy, and follow-up, including to palliative care and grief support where these were required. They coordinated preventive programs, such as cervical smear and mammogram recall registers, and coordinated health promotion activities to promote prevention and early detection of other cancers, such as bowel cancer, skin cancer, liver cancer and prostate cancer. The program was evaluated qualitatively using semistructured interviews with current clients of the cancer care team and stakeholders, using grounded theory to analyse emerging themes., Setting: An Australian Aboriginal community-controlled health service in New South Wales., Participants: The cancer care team provided care for 79 clients., Main Outcome Measures: Acceptability and accessibility of cancer care services., Results: The evaluation involved recruitment of eight Australian Aboriginal clients of the cancer care team and eight stakeholders. The main themes to emerge included improved accessibility of cancer care services, including availability of home visits, transport and accompaniment to tertiary settings. The service was viewed as being culturally safe., Conclusion: A primary care-based cancer care team in an Australian Aboriginal medical service provided a culturally safe and accessible service for clients., (© 2019 National Rural Health Alliance Ltd.)

Background: The post-take ward round (PTWR) provides formal consultant review of acutely unwell patients admitted to hospital, yet specialist medical registrars, the consultants of tomorrow, receive little to no formal training in this area. There is an expectation that 'on the job' experience will provide sufficient preparation for this important aspect of clinical leadership., Methods: We aimed to seek the opinions of medical registrars on the use of a structured considerative checklist and learning-by-example approach in PTWR leadership training, assessing whether this model influences current and future practice. This was studied through a questionnaire-based survey of medical registrars working in Worthing Hospital from 2009 to 2011., Results: Eighteen of 25 registrars (72%) across a range of specialties returned questionnaires. Although a third of respondents had spent time considering how they conduct ward rounds, none had received formal training, with most feeling that ward round skills were acquired 'on the job' from observation and experience of those conducted by senior colleagues. Exposure to the considerative checklist changed thinking in 94 per cent and changed practice in 88 per cent. Common positive themes included enhanced pre-ward round preparation, the importance of inclusion and communication, and the need for structure (facilitated by physical or mental checklist). Seventeen of 18 participants felt that this training would influence their consultant practice., Discussion: Trainees respond positively to participation in a structured PTWR using a considerative checklist as a model of good practice, leading to changes in their current and future practice, and could be considered as a training tool., (© 2014 John Wiley & Sons Ltd.)