The mysteries and demands of HIV care: qualitative analyses of HIV specialists’ views on their expertise

At the coalface and the cutting edge: general practitioners' accounts of the rewards of engaging with HIV medicine

Background

HIV has become a chronic manageable infection in the developed world, and early and lifelong treatment has the potential to significantly reduce transmission rates in the community. A skilled and motivated HIV medical workforce will be required to achieve these health management and prevention outcomes, but concerns have been noted in a number of settings about the challenges of recruiting a new generation of clinicians to HIV medicine.

Methods

As part of a larger qualitative study of the HIV general practice workforce in Australia, in-depth interviews were conducted with 31 general practitioners accredited to prescribe HIV medications in community settings. A thematic analysis was conducted of the de-identified transcripts, and this paper describes and interprets accounts of the rewards of pursuing and sustaining an engagement with HIV medicine in general practice settings.

Results

The rewards of initially becoming involved in providing care to people living with HIV were described as interest and inspiration, community calling and right place, right time. The rewards which then supported and sustained that engagement over time were described as challenge and change, making a difference and enhanced professional identity. Participants viewed the role of primary care doctor with special expertise in HIV as occupying an ideal interface between the ‘coalface’ and the ‘cutting edge’, and offering a unique opportunity for general practitioners to feel intimately connected to both community needs and scientific change.

Conclusions

Approaches to recruiting and retaining the HIV medical workforce should build upon the intellectual and social rewards of this work, as well as the sense of professional belonging and connection which is imbued between both doctors and patients and across the global and national networks of HIV clinicians. Insights regarding the rewards of engaging with HIV medicine may also be useful in enhancing the prospect of general practice as a career, and strengthening retention and job satisfaction among the existing general practice workforce.

Challenges, coping strategies, and recommendations related to the HIV services field in the HAART era: a systematic literature review of qualitative studies from the United States and Canada

Qualitative research methods have been utilized to study the nature of work in the HIV services field. Yet current literature lacks a Highly Active Anti-Retroviral Treatment (HAART) era compendium of qualitative research studying challenges and coping strategies in the field. This study systematically reviewed challenges and coping strategies that qualitative researchers observed in the HIV services field during the HAART era, and their recommendations to organizations. Four online databases were searched for peer-reviewed research that utilized qualitative methods, were published from January 1998 to February 2012, utilized samples of individuals in the HIV services field; occurred in the U.S. or Canada, and contained information related to challenges and/or coping strategies. Abstracts were identified (n=846) and independently read and coded for inclusion by at least two of the four first authors. Identified articles (n=26) were independently read by at least two of the four first authors who recorded the study methodology, participant demographics, challenges and coping strategies, and recommendations. A number of challenges affecting those in the HIV services field were noted, particularly interpersonal and organizational issues. Coping strategies were problem- and emotion-focused. Summarized research recommendations called for increased support, capacity-building, and structural changes. Future research on challenges and coping strategies must provide up-to-date information to the HIV services field while creating, implementing, and evaluating interventions to manage current challenges and reduce the risk of burnout.

Health care provider perspectives on informal supporters' involvement in HIV care

Positive social support has been associated with medication adherence and slowed disease progression among people living with HIV. The nature of support within the medical context itself has not been adequately investigated, however. The purpose of our study was to describe HIV health care providers' perspectives on informal supporter-oriented health care and whether and how the involvement of patients' adult informal supporters in health care and health care decision making is helpful or beneficial. We conducted in-depth qualitative interviews with 11 HIV specialists between March and September, 2005. Using directed qualitative content analysis, we first describe the frequency and course of others' involvement and the type of support provided. We then situate these findings within the context of role theory and consider the meaning they have in terms of the negotiated relationships among and between patients, providers, and informal supporters. Finally, we provide research and clinical recommendations based on these findings that are designed to improve patient care.

High HIV knowledge relates to low stigma in pharmacists and university health science students in Guyana, South America

OBJECTIVES

The objective of this study was to investigate HIV knowledge and its relation to HIV stigma among health science students and pharmacists in Guyana, South America. This study also evaluated how the Public Health Strengthening in Guyana Project's (PHSGP) HIV/AIDS/STI educational initiatives influenced HIV knowledge levels among health science students at the University of Guyana.

METHODS

A total of 119 individuals, consisting of pharmacists (n=42) and health science students (n=77) participated in this cross-sectional study. All participants completed validated measures of HIV knowledge and HIV stigma.

RESULTS

Overall, health science students scored high on knowledge about HIV risk factors and modes of HIV infection, but were less knowledgeable about more complex HIV treatment issues such as adherence and drug resistance. Students who had received educational HIV training had significantly higher levels of HIV knowledge than those who had not received training. Pharmacists had excellent knowledge regarding HIV risk factors and modes of infection, but had some important gaps in knowledge regarding the importance of HIV medication adherence and drug resistance. Overall, low levels of HIV stigma were endorsed, and those with higher HIV knowledge reported lower HIV stigma.

CONCLUSIONS

Although the HIV curriculum has enhanced HIV knowledge, gaps in HIV knowledge remain, such as complex HIV treatment issues. The results of this study are discussed within the context of the challenges of HIV capacity building in resource-poor countries.

Organizing "mountains of words" for data analysis, both qualitative and quantitative

Qualitative research creates mountains of words. U.S. federal funding supports mostly structured qualitative research, which is designed to test hypotheses using semiquantitative coding and analysis. This article reports on strategies for planning, organizing, collecting, managing, storing, retrieving, analyzing, and writing about qualitative data so as to most efficiently manage the mountains of words collected in large-scale ethnographic projects. Multiple benefits accrue from this approach. Field expenditures are linked to units of work so productivity is measured, many staff in various locations have access to use and analyze the data, quantitative data can be derived from data that is primarily qualitative, and improved efficiencies of resources are developed.

Impact on HIV test providers of giving a positive test result

The provision of a positive HIV antibody test result and the direction and support given to the test recipient are critical components of care and prevention. There has been little research that describes what happens in such interactions between recipient and provider. The impact on the test provider of delivering the HIV test result is an important issue to consider. The discomfort experienced by some health providers in giving a positive test result may have adverse effects on the client interaction or may carry over into subsequent client interactions. Utilizing a thematic analysis on interview data from 24 HIV test providers, we describe the impact of delivering a positive test result on HIV test providers, identify the factors that influence this impact, and describe strategies used to manage the impact. As with other health care professionals communicating "bad news,"HIV test providers experience a variety of impacts. While a small number of providers indicated little or no impact of delivering the HIV positive test result because the diagnosis is ''not the end of the world,'' most indicated it was difficult as it was anticipated that the test recipient would (or did) find the news distressing. Several coping strategies were identified.

Outcomes of dosage adjustments used to manage antiretroviral drug interactions

Dosage adjustments are often used to manage HIV drug interactions, but little is known about their clinical significance. We examined patients from the Ontario HIV Cohort Study to assess the effects of dosage adjustments on plasma viral load. A significant reduction (0.67 log10 copies/mL) in viral load was associated with adjustments to manage efavirenz-based interactions (95% confidence interval, -1.33 to -0.01) but was not observed after adjustments to manage rifabutin-based (difference in viral load, 0.03 log10 copies/mL; 95% confidence interval, -0.71 to 0.77) or nevirapine-based interactions (difference in viral load, 0.09 log10 copies/mL; 95% confidence interval, -0.83 to 1.01).

Uncertainty and 'technological horizon' in qualitative interviews about HIV treatment

Highly Active Anti-Retroviral Treatment (HAART) has reduced death and morbidity among people with HIV. However, HAART is not always effective, can produce serious side-effects and implies uncertainty for patients. To address HAART-related uncertainty, 20 qualitative interviews were conducted with gay men with HIV in Glasgow and London. The interviewees were purposively selected to reflect diversity in terms of year of diagnosis, experiences of illness and treatment-related side-effects. The interviews were analysed using the constant comparison method to derive themes. Among those using HAART, analysis identified themes of 'good health', 'illness' and 'loss of confidence'. Uncertainty was managed through a discourse of 'technological horizon' that combined the ongoing innovations of HAART and biographical time. These themes are discussed in terms of the implications for HIV care. In particular, technological horizon provides a basis for the management of uncertainty in the prescribing relationship between patient and clinician.

Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS

This article is a review of some of the major epidemiological, behavioral, biological, and integrative prevention research issues and priorities in the area of HIV/AIDS and alcohol consumption. Drinking alcohol increases both the risk for infection with HIV and related illnesses and the morbidity and mortality of patients who progress to AIDS. New and improved measurement procedures have helped in assessment of the complex patterns of alcohol use, identification of intervening explanatory mechanisms for risk behaviors and contexts, and determination of intervention outcomes. Both the direct and indirect effects of alcohol misuse appear to be major contributors to both the risk for infection with HIV and the transmission of HIV/AIDS at the individual and population levels. There is increasing evidence that perhaps no level of alcohol consumption is "safe" for those who are HIV infected and receiving antiretroviral treatment. Interdisciplinary basic behavioral and biomedical research is needed to develop comprehensive culturally appropriate strategies for programs that can be effectively delivered in community contexts in the United States and abroad and that focus on the integration of our understanding of individual behaviors, high-risk group membership, biological mechanisms, and the social and physical environments that place individuals at risk for HIV infection. High-priority topics include improving adherence to antiretroviral medications, prevention of infection in young minority women in the United States, and treatment of HIV+ pregnant women who are alcohol abusers to prevent adverse fetal outcomes, which is an international focus in under-resourced settings in Africa.

Managing uncertainty around HIV/AIDS in an urban setting: Private medical providers and their patients in Pune, India

Changing epidemiological patterns and the advent of new rapid diagnostic technologies and therapies have created considerable uncertainty for providers working in HIV. In India, the demand for HIV care is increasingly being met by private practitioners (PPs), yet little is known about how they deal with the challenges of managing HIV patients. To explore HIV management practices in the private medical sector, a survey was conducted with 215PPs in Pune, India, followed by in-depth interviews focusing on the social context of practice among a sub-set of 27PPs. Drawing primarily on interview data, this paper illustrates a number of uncertainties that underlie the reported actions of providers in a competitive medical market. PPs perceive HIV as a 'new' and challenging disease for which they lack adequate knowledge and skills. Combined with the perceived high cost and complexity of antiretroviral treatment, preconceptions about HIV patients' social, financial and mental capacity lead to highly individualistic management practices. While these fall short of clinical 'best practice' guidelines, they reflect adaptive responses to the wider uncertainties surrounding HIV care in urban India. By highlighting contextual issues in PPs' management of HIV patients, the paper suggests the need to explicitly acknowledge the social, moral and economic bases of uncertainty beyond the clinical setting.