HIV care: non-ID providers do better

 A recent paper found that HIV care provided by non-infectious disease specialists was in some ways superior to that provided by ID specialists (see hiv primary care better than non-ID providers JAIDS2024 in dropbox or 10.1097/QAI.0000000000003410)

 

Details:

-- 6323 adults receiving HIV care were analyzed from the CDC’s Medical Monitoring Project (MMP), from 2019-2021

    -- MMP is an annual cross-sectional survey designed to produce nationally representative estimates of the behavioral and clinical characteristics of adults with HIV diagnoses through routine public health surveillance.

    -- the random set of people sampled in the 2019 and 2020 data collection cycles were recruited for a phone or face-to-face interview

    -- the following states were included: California, Delaware, Florida, Georgia, Illinois, Indiana, Michigan, Mississippi, New Jersey, New York, North Carolina, Oregon, Pennsylvania, Puerto Rico, Texas, Virginia, and Washington

-- male 75%, transgender 2%, gay or lesbian 44%, 41% Black/24% Latino/30% white, age 18 to 34 in 17%/45 to 54 in 27%/> 55 in 40%; 39% had income<100% of the federal poverty limit

-- discrimination in HIV care setting in 21%

-- advanced HIV 15%, CD4 0-199 8%/200-349 10%/350-499 17%/>500 65%

-- heavy alcohol use 5%, any drug use in the past 12 months 32%, non-monogamous 43% (75% of these did not use condoms), anxiety 14%, depression 15%

-- education less than high school in 16%/high school 26%/more than high school 59%; homelessness/unstable housing in 17%, incarcerated 4%, public health insurance 53%, Ryan White/ADAP 9%

    -- the Ryan White Comprehensive AIDS Resources Emergency Care Act was legislatively created in 1990 to improve the quality and availability of HIV care and treatment to low-income people with HIV, through the Ryan White HIV/AIDS Program (RWHAP) 

 

-- results below were adjusted for demographic and clinical characteristics, social determinants of health, RWHAP care funding status, geographic location

-- main outcomes: retention in care; antiretroviral therapy (ART) prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia and syphilis testing; satisfaction with HIV care; and HIV provider trust

-- these aspects of care were compared between ID physicians, non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus NPs and/or PAs

 

Results:

-- general differences amongst patients being treated by these different groups:

    -- compared with patients of ID physicians, patients of non-ID physicians were less likely to be Black/more likely to be Latino, more likely to have less than high school education, and were more likely to report discrimination in HIV care setting; those seen only by nurse practitioners only were more likely to be Black, younger, poorer, less educated, have less health care coverage, more likely to have unstable housing or be homeless and recently incarcerated, and more likely to be in a RWHAP-funded facility; those treated by PAs only were younger, more likely to have private insurance, more likely to be more impoverished, and more likely to have unstable housing or being recently incarcerated or to have used any injection or non-injection drugs, and to have receive care in a RWHAP-funded facility

 

-- differences in the prevalence of HIV care outcomes in the past 12 months:

    -- retained in care: ID physicians 83.1% versus non-ID physicians 89.7%, adjusted prevalence difference (aPD) 6.5 percentage points (2.7-10.3), p=0.001. aPD for nurse practitioners was 5.6 percentage points (2.3-8.9), p<0.001, and for physician assistants was nonsignificant

    -- STI testing for gonorrhea, chlamydia, and syphilis: ID physicians 40.1% versus non-ID physicians 49.5%, aPD 6.9 percentage points (0.8-13.1), p=0.044; nurse practitioners aPD 7.4 percentage points (1.6-13.3), p=0.012, physician assistants not significant

    -- receiving ART prescriptions, ART adherence, sustained viral suppression, being very satisfied with HIV care, and provider trust scale were not statistically different between groups

    -- of note, the combination of ID physicians along with either nurse practitioner or physician assistant did significantly better than being cared for by ID physicians only

 

Commentary:

-- the incentive for including more non-ID physicians in providing HIV care is that the 2019 US Dept of Health and Human Service’s initiative of Ending the HIV Epidemic in the US will required more providers (exceeding available ID clinicians) who are able to take care of HIV patients, with the goal of ending the HIV epidemic by 2030

-- there clearly are advantages to non-ID specialists caring for patients with HIV:

    -- HIV care at this point in time is typically quite straightforward: the current drug regimens, especially those incorporating INSTIs (integrase strand transfer inhibitors) are incredibly easy to take (mostly one pill a day), remarkably effective, and have minimal adverse effects (the weight gain is a bit of a concern: eg see https://gmodestmedblogs.blogspot.com/2020/10/hiv-treatmentprevention-guidelines-2020.html ), though eliminating TAF as a component, as with the dolutegravir/lamivudine combo, should help with that as well as decreasing the potential adverse long-term effects on bone and kidneys)

    -- most patients on these medications rapidly achieve complete HIV viral suppression and dramatic improvement in their CD4 counts and require only occasional blood tests only.

        -- primary care clinicians typically pay attention to several other relevant HIV-related issues such as the increased cervical cancer screening for women with HIV, increased anal cancer screening, routine STI screening, consideration of preexposure/postexposure prophylaxis, etc.

        -- primary care providers also have the benefit of incorporating HIV care into holistic care for the patients, including screening for other HIV-related problems (e.g. being more alert to the persistent increase in cancers in those with even controlled HIV, higher incidence of coronary vascular disease, etc.), as well as the array of other medical and psychosocial issues that patients have

    -- by having all of this care provided at the same time, there is less fragmentation of care, fewer appointments in different locations and with different providers, perhaps savings in the co-pays that patients have to pay for visits, etc.

    -- and, when complex HIV care decisions need to be made (e.g. patients who are less well HIV-suppressed who may have complex med resistance patterns), there certainly may be a role for ID specialists locally, as well as availability of a national warmline for providers for guidance: https://aidsetc.org/aetc-program/nccc , phone number 1-833-622-2463. I personally have used this warmline in the past for some of my complex patients, and have received great information on how to interpret the resistance genotype and what medications would be best to provide. Though, I should add, with these fantastic newer medications, it is very rare for me to see a patient who does not have an excellent response (this is largely confined to patients who are or have been inconsistent in their medication taking)

    -- also, there may well be patients who see ID specialists who do not see other clinicians for their other important primary care issues (immunizations, screening tests, other potential health, lifestyle, psychosocial issues, etc)

 

-- This study basically found that non-ID physicians, NPs, and practices with mixed providers were more likely to have their patients be retained in care and have recommended STI testing in the past 12 months (if they were sexually active). Most other outcomes were pretty equivalent between the groups. Overall, the ID physicians in this group were less likely to have patients with the characteristics and social determinants of health associated with poor health outcomes. This, of course, may vary dramatically from one area of the country to another...

-- however, this finding of less STI testing in patients seen only by ID physicians is distressing, given the pretty dramatic increase in STIs in the US (see https://gmodestmedblogs.blogspot.com/2022/08/stds-increasing.html )

-- a different study from this same MMP database found that NPs were twice as likely as ID physicians to report providing comprehensive sexual behavior-related risk reduction services; that study also found that one third of ID physicians reported not providing: primary care for HIV patients (defined as being the point of first contact), providing comprehensive care, and emphasizing prevention and coordination of care (versus one in 10 non-ID physicians and NPs, and less than 1% of PAs)

 

Limitations:

-- the study was based on the patients usual place of outpatient HIV care, though some of the patients may have had testing performed elsewhere

-- informal consultations with ID specialists or others were not included in this MMP information database

-- much of the demographic and social determinants of health information was patient-reported and perhaps reflected an information accuracy bias

-- some of data collected was during the Covid pandemic, which could have affected the results

-- it is difficult to attribute causality from this data, since this was a retrospective analysis and might involve residual confounding

-- there were pretty large differences in the numbers of patients being seen by these different providers: 285 treated by ID physicians vs 109 by non-ID physicians; 907 by nurse practitioners vs 240 by physician assistants; and 607 by the combo of ID physician and either NP or PA

 

so,

-- this study does support the key role that primary care clinicians can take in helping patients with HIV

-- the involvement of primary care clinicians will likely result in a more holistic approach to the overall care of these individuals, since so many patients have other medical or psychosocial problems.

    -- and, a cornerstone of primary care is understanding patients fully, in the context of their family, community, culture, and important social issues

    -- primary care physicians are also very likely to have more frequent contact with patients than ID specialists, since we are also taking care of all of these other issues. and the more frequent contacts will tend to inform us of a better longitudinal understanding of who the patients are and what their needs are, as well as cementing a more comprehensive therapeutic interpersonal relationship

 

 

geoff

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