Advances in antiretroviral therapy have resulted in longer lives for people with HIV. To meet the needs of this growing, aging HIV population, Mount Sinai’s Brookdale Department of Geriatrics and Palliative Medicine has partnered with Mount Sinai’s Institute for Advanced Medicine to create the Comprehensive Care for Older Adults With HIV Program.
The program uses a collaborative team approach to address the many needs of these patients. The team includes a geriatrician, registered nurse, pharmacist, social worker, and community health worker (CHW). The program’s major innovation is the community health worker, who serves as advocate, coordinator, and educator for patients. Based on its success, Mount Sinai began rolling out the program to other institutions nationwide in December 2025.
The program, directed by Angela Condo, MD, 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. Using specialized clinical screening tools to assess Mobility, Mind, Medications, Multi-complexity, Modifiable issues, and what Matters Most (to patients), the clinical team develops a care plan, with appropriate clinical and community referrals, that addresses common conditions of aging. The program is located at the Institute for Advanced Medicine’s Peter Krueger Clinic in New York City.
The program has been shown to improve health outcomes for older adults with HIV by providing age-appropriate patient-centered care, enhancing efficiency and teamwork, understanding and aligning patient goals with their treatment, and reducing the number of missed appointments.
“Just as we have done over the years with many other programs that address the health needs of older adults, we look forward to disseminating this to institutions across the country, who can replicate it and customize it to the needs of their patients and providers,” says Fred Ko, MD, Associate Professor, Geriatrics and Palliative Medicine, and Demonstration Project Administrator/Evaluator.
“What makes this project so effective is the involvement of a community health worker, which is the backbone of the program,” says Fred Ko, MD, Associate Professor, Geriatrics and Palliative Medicine, and Demonstration Project Administrator/Evaluator. “By incorporating a CHW on our team, we enable our patients to gain access to all the services Mount Sinai provides and, importantly, the community health workers build relationships with patients who can now rely on a reliable, caring professional to help them navigate the system.”
Community health workers play a key role on the health care team, serving as a bridge between medical providers and the patients and their caregivers, helping to identify and access necessary services within the Mount Sinai Health System and the community.
Older adults with HIV tend to have more complex needs, including more medical conditions and psychosocial challenges, such as elevated rates of depression, anxiety, loneliness, and social isolation, compared to other older adults. They may also struggle more with food and housing insecurity than most of their peers.
To address these challenges, the community health workers help patients make appointments, provide scheduling reminders, support patients during program visits, administer some geriatric screenings and assessments, and offer culturally appropriate education around the principles of aging. They also identify transportation needs, provide referral information, and coordinate appointments with other specialists, as needed. They are involved before, during, and after patients’ appointments.
Patients are referred to the program for a variety of reasons, including cognitive concerns, mobility difficulties, and complex medication needs (typically five or more prescriptions). Referrals are made by HIV providers within the Institute for Advanced Medicine at Mount Sinai, which serves more than 9,000 patients from the New York metro area, more than half over age 50.
“This transformative program has demonstrated success in improving health outcomes for older adults with HIV,” says Dr. Condo. “Just as we have done over the years with many other programs that address the health needs of older adults, we look forward to disseminating this to institutions across the country, who can replicate it and customize it to the needs of their patients and providers.”
The Comprehensive Care for Older Adults With HIV Program receives funding from the Keith Haring Foundation and the U.S. Health Resources and Services Administration.
For more information about the Comprehensive Care for Older Adults With HIV Program, including making it available locally, please visit mountsinai.org/geriHIV or contact AgingwithHIV@mssm.edu.