Effect of physician specialty on counseling practices and medical referral patterns among physicians caring for disadvantaged human immunodeficiency virus-infected populations

Responding to the HIV Health Literacy Needs of Clients in Substance Use Treatment: The Role of Universal PrEP Education in HIV Health and Prevention

Health literacy, particularly HIV health literacy, is a key social determinant of health and can be significantly improved through targeted health education. This paper explores the often-overlooked potential of pre-exposure prophylaxis (PrEP) education as a powerful tool to enhance HIV health literacy among people with substance use disorders (PWSUD), a population notably susceptible to HIV. Given the syndemic interplay of substance use disorders (SUDs) and HIV, health professionals, especially substance use counselors, are uniquely positioned to bolster HIV health literacy and positively influence health outcomes. This article offers a brief introduction to PrEP, delineates potential barriers and facilitators to its use and education, and proposes strategies for effective PrEP education, implementation, and adherence. By equipping substance use counselors with essential knowledge and skills, we aim to encourage and promote the integration of PrEP education into substance use treatment. The overarching objective is to empower counselors to proactively engage in HIV prevention efforts, thereby fulfilling pressing health literacy needs and contributing to improved health outcomes among PWSUD.

The impact of physician subspeciality on the quality of diabetes care for people living with HIV

BACKGROUND

Management of comorbidities of people living with HIV (PLHIV) involves different care models, including providing diabetes care and HIV care by the same infectious diseases physician (IDP) ("consolidated care") or providing diabetes care by the physicians other than IDP ("shared care"). The impact of diabetes care model on PLHIV with diabetes mellitus (DM) has not been well-evaluated.

METHODS

A nationwide cross-sectional sample in the Taiwan National Health Insurance Research Database was used to compare the performance rates of seven guideline-recommended tests provided by the different subspecialists.

RESULTS

Of 523 PLHIV with DM, there were 54.88% (n = 287) in the consolidated care group and 45.12% (n = 236) in the shared care group. More patients in the consolidated care group received the tests of lipid profile (92.33% vs. 79.24%), creatinine (Cr) (93.73% vs. 78.39%), and alanine transaminase (ALT) (91.99% vs. 75.42%), but fewer received urine protein test (35.54% vs. 51.69%) and fundoscopic examination (8.01% vs. 33.90%). The two groups did not differ in the performance rates of serum fasting glucose and HbA1c. After controlling for demographic factors and diabetic severity, the consolidated group was less likely to miss the serum tests of lipid profile (odds ratio [OR]: 0.30), Cr (OR: 0.19), and ALT (OR: 0.23), but more often missed urine protein test (OR: 1.56) and fundoscopic examination (OR: 4.97).

CONCLUSION

These findings suggest the need to focus on different process indicators of diabetes cares in different care models to enhance the diabetes care for PLHIV.

Individual-Level and Clinic-Level Factors Associated With Achieving Glycemic Control in a Large Cohort of People With HIV in Care-Washington, DC

BACKGROUND

Optimal management of noncommunicable diseases, including diabetes mellitus (DM), is crucially important as people with HIV (PWH) live longer with antiretroviral therapy. Our objective was to assess patient-level and clinic-level factors associated with achieving hemoglobin A1c (HbA1c) ≤7.0% among PWH and DM.

SETTING

The DC Cohort, an observational clinical cohort of PWH, followed from 2011 to 2019 at 12 sites in Washington, DC.

METHODS

Among PWH with diagnosed DM and elevated HbA1c (>7.0%), we examined the association between achieving HbA1c ≤7.0% and demographic and clinical factors, including time-updated medication data, and clinic-level factors related to services and structure. A multilevel marginal extended Cox regression model was generated to identify factors associated with time to HbA1c ≤7.0%.

RESULTS

Over half (52.3%) of 419 participants achieved HbA1c ≤7.0%. Individual-level factors associated with HbA1c ≤7.0% included a diagnosis of DM after enrollment and a longer time since HIV diagnosis [hazard ratio (HR) = 2.65 and 1.13, P < 0.05 for both]. Attending a clinic with an endocrinologist was associated with the outcome [adjusted HR (aHR) = 1.41 95% confidence interval (CI): (1.01 to 1.97)]. In addition, comparing clinics that treat everyone, refer everyone or have a mix of treating and referring, showed an association between attending a clinic that treats everyone [aHR = 1.52 95% CI: (1.21 to 1.90)] or a clinic that refers everyone [aHR = 2.24 95% CI: (1.63 to 3.07)] compared with clinics with a mix in achieving glycemic control.

CONCLUSION

Multiple factors are associated with achieving glycemic control in an urban cohort of PWH. Determining if specific services or structures improve DM outcomes may improve health outcomes for PWH and DM.

Physician network connections to specialists and HIV quality of care

OBJECTIVE

To estimate novel measures of generalist physicians' network connectedness to HIV specialists and their associations with two dimensions of HIV quality of care.

DATA SOURCES

Medicare and Medicaid claims and the American Medical Association Masterfile data on people living with HIV (PLWH) and the physicians providing their HIV care in California between 2007 and 2010.

STUDY DESIGN

I construct regional patient-sharing physician networks from the shared treatment of PLWH and calculate (a) measures of network connectedness to all physician types and (b) specialty-weighted measures to describe connectedness to HIV specialists. Two HIV quality of care outcomes are then evaluated: medication quality (prescribing antiretroviral drugs from at least two drug classes) and monitoring quality (at least two annual HIV virus monitoring scans). Linear probability models estimate the associations between network statistics and the two dimensions of HIV quality of care, and a policy simulation demonstrates the importance of these statistical relationships. These analyses include 16 124 PLWH, 3240 generalists, and 1031 HIV specialists.

DATA COLLECTION/EXTRACTION METHODS

PLWH are identified from claims for patients with any indication of HIV using an existing algorithm from the literature.

PRINCIPAL FINDINGS

Generalists' network connectedness to HIV specialists is positively related with their own HIV medication quality; one additional HIV specialist connection is associated with a 1.46 percentage point (SE 0.42, P < .01) increase in generalist's medication quality. Based on the estimated associations, a simulated policy that increases connectedness between generalists and HIV specialists reduces the annual rate of HIV infections by up to 6%, roughly 290 fewer infections per year. Only network connectedness to all physician types is associated with improved monitoring quality.

CONCLUSIONS

Network connectedness to HIV specialists is positively associated with generalists' HIV medication quality, which suggests that specialists provide clinical support through patient-sharing for complex treatment protocol.

How the delivery of HIV care in Canada aligns with the Chronic Care Model: A qualitative study

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada.

Cancer disparities in people with HIV: A systematic review of screening for non-AIDS-defining malignancies

BACKGROUND

People with HIV (PWHIV) have improved survival because of the advent of antiretroviral therapy. Consequently, PWHIV experience higher rates of non-acquired immunodeficiency syndrome-defining malignancies (NADMs). Previous studies have demonstrated worsened cancer-specific survival in PWHIV, partly because of advanced cancer stage at diagnosis. The objective of the current systematic review was to evaluate screening disparities for NADMs among PWHIV.

METHODS

The PubMed, Cochrane, EMBASE, and ClinicalTrials.gov databases were searched from January 1, 1996 through April 10, 2018 to identify studies related to screening disparities for NADMs among PWHIV. Eligibility criteria included any study performed in a high-income country that compared screening for NADMs by HIV status. After title/abstract screening and full-text review, articles that met eligibility criteria were analyzed.

RESULTS

Of 613 unique articles identified through the search, 9 studies were analyzed. Three studies addressed breast cancer screening, 4 addressed colorectal cancer screening, and 2 addressed prostate cancer screening. Five of the reviewed studies demonstrated that PWHIV were less likely to receive indicated cancer screenings compared with the general population, whereas 3 indicated that screening proportions were higher among PWHIV, and 1 demonstrated that screening proportions were comparable. In most of the studies, PWHIV who had regular access to health care were more likely to undergo cancer screening.

CONCLUSIONS

The available evidence does not uniformly confirm that PWHIV are less likely to receive cancer screening. Social determinants of health (insurance status, access to health care, education, income level) were associated with the receipt of appropriate cancer screening, suggesting that these barriers need to be addressed to improve cancer screening in PWHIV.

HIV primary care by the infectious disease physician in the United States - extending the continuum of care

Models of care for people living with HIV (PLWH) have varied over time due to long term survival, development of HIV-associated non-AIDS conditions, and HIV specific primary care guidelines that differ from those of the general population. The objectives of this study are to assess how often infectious disease (ID) physicians provide primary care for PLWH, assess their practice patterns and barriers in the provision of primary care. We used a 6-item survey electronically distributed to ID physician members of Emerging Infections Network (EIN). Of the 1248 active EIN members, 644 (52%) responded to the survey. Among the 644 respondents, 431 (67%) treated PLWH. Of these 431 responders, 326 (75%) acted as their primary care physicians. Responders who reported always/mostly performing a screening assessment as recommended per guidelines were: (1) Screening specific to HIV (tuberculosis 95%, genital chlamydia/gonorrhoea 77%, hepatitis C 67%, extra genital chlamydia/gonorrhoea 47%, baseline anal PAP smear for women 36% and men 34%); (2) Primary care related screening (fasting lipids 95%, colonoscopy 95%, mammogram 90%, cervical PAP smears 88%, depression 57%, osteoporosis in postmenopausal women 55% and men >50 yrs 33%). Respondents who worked in university hospitals, had <5 years of ID experience, and those who cared for more PLWH were most likely to provide primary care to all or most of their patients. Common barriers reported include: refusal by patient (72%), non-adherence to HIV medications (43%), other health priorities (44%), time constraints during clinic visit (43%) and financial/insurance limitations (40%). Most ID physicians act as primary care providers for their HIV infected patients especially if they are recent ID graduates and work in university hospitals. Current screening rates are suboptimal. Interventions to increase screening practices and to decrease barriers are urgently needed to address the needs of the aging HIV population in the United States.

Non-Communicable Disease Preventive Screening by HIV Care Model

Importance

The Human Immunodeficiency Virus (HIV) epidemic has evolved, with an increasing non-communicable disease (NCD) burden emerging and need for long-term management, yet there are limited data to help delineate the optimal care model to screen for NCDs for this patient population.

Objective

The primary aim was to compare rates of NCD preventive screening in persons living with HIV/AIDS (PLWHA) by type of HIV care model, focusing on metabolic/cardiovascular disease (CVD) and cancer screening. We hypothesized that primary care models that included generalists would have higher preventive screening rates.

Design

Prospective observational cohort study.

Setting

Partners HealthCare System (PHS) encompassing Brigham & Women’s Hospital, Massachusetts General Hospital, and affiliated community health centers.

Participants

PLWHA age >18 engaged in active primary care at PHS.

Exposure

HIV care model categorized as infectious disease (ID) providers only, generalist providers only, or ID plus generalist providers.

Main Outcome(s) and Measures(s)

Odds of screening for metabolic/CVD outcomes including hypertension (HTN), obesity, hyperlipidemia (HL), and diabetes (DM) and cancer including colorectal cancer (CRC), cervical cancer, and breast cancer.

Results

In a cohort of 1565 PLWHA, distribution by HIV care model was 875 ID (56%), 90 generalists (6%), and 600 ID plus generalists (38%). Patients in the generalist group had lower odds of viral suppression but similar CD4 counts and ART exposure as compared with ID and ID plus generalist groups. In analyses adjusting for sociodemographic and clinical covariates and clustering within provider, there were no significant differences in metabolic/CVD or cancer screening rates among the three HIV care models.

Conclusions

There were no notable differences in metabolic/CVD or cancer screening rates by HIV care model after adjusting for sociodemographic and clinical factors. These findings suggest that HIV patients receive similar preventive health care for NCDs independent of HIV care model.

Quality of Care for HIV/AIDS and for Primary Prevention by HIV Specialists and Nonspecialists

The role of HIV specialists in providing primary care to persons living with HIV/AIDS is evolving, given their increased incidence of comorbidities. Multivariate logit analysis compared compliance with sentinel preventive screening tests and interventions among publicly insured Californians with and without access to HIV specialists in 2010. Quality-of-care indicators [visit frequency, CD4 and viral load (VL) assessments, influenza vaccine, tuberculosis (TB) testing, lipid profile, glucose blood test, and Pap smears for women] were related to patient characteristics and provider HIV caseload. There were 9377 adult Medicare enrollees (71% also had Medicaid coverage) and 2076 enrollees with only Medicaid coverage. Adjusted for patient characteristics, patients seeing providers with greater HIV caseloads (>50 HIV patients) were more likely to meet visit frequency guidelines in both Medicare [98%; confidence interval (CI 97.5-98.2) and Medicaid (97%; CI 96.2-98.0), compared to 60% (CI 57.1-62.3) and 45% (CI 38.3-50.4), respectively, seeing providers without large HIV caseloads (p < 0.001). Patients seeing providers with larger caseloads were significantly more likely to have CD4 (p < 0.001), VL (p < 0.001), and TB testing (p < 0.05). A larger percentage of patients seeing large-volume Medicare providers received influenza vaccinations. Provider caseload was unrelated to lipid or glucose assessments or Pap Smears for women. Patients with access to large-volume providers were more likely to meet clinical guidelines for visits, CD4, VL, tuberculosis testing, and influenza vaccinations, and were not less likely to receive primary preventive care. Substantial insufficiencies remain in both monitoring to assess viral suppression and in preventive care.

Managing the Personal Side of Health Care among Patients with HIV/AIDS

The study describes the HIV care providers' sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers' perspectives may help enhance support services, patients' ongoing care and retention, leading to improved health outcomes.

A population-based study evaluating family physicians' HIV experience and care of people living with HIV in Ontario

PURPOSE

Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV.

METHODS

We retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period).

RESULTS

The majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients (mean levels of adherence [95% CIs] were 0.34 [0.30-0.39] and 0.40 [0.34-0.45], respectively, vs 0.77 [0.74-0.80]). Patients' receipt of cancer screenings and health care use were unrelated to family physician HIV experience.

CONCLUSIONS

Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings.

A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario

OBJECTIVES

Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided.

DESIGN

Retrospective population-based observational study from 1 April 2009 to 31 March 2012.

PARTICIPANTS

13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care.

OUTCOME MEASURES

Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses.

RESULTS

Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physician-dominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIV-specific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients' HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)).

CONCLUSIONS

How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures.

Knowledge is Power! Increased Provider Knowledge Scores Regarding Pre-exposure Prophylaxis (PrEP) are Associated with Higher Rates of PrEP Prescription and Future Intent to Prescribe PrEP

The FDA approval of emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP) in 2012 has raised questions about the delivery of PrEP in a real-world setting. iPad-based questionnaires were given to providers at conferences in California and New York to assess knowledge, experience and attitudes regarding PrEP in HIV and non-HIV providers. HIV provider status was defined either by self-identification or by having greater than 5 years of HIV care experience. Knowledge scores were the sum of correct answers from five PrEP knowledge questions. Univariate analyses used t-test to compare knowledge scores and Fisher's exact test for past or future PrEP prescription between HIV and non-HIV providers. Multivariable linear or logistic regression models were used to assess factors associated with the outcomes. Of 233 respondents, the mean age was 40 years, 59 % were White, 59 % were physicians and 52 % were HIV providers. In univariate analysis, mean PrEP knowledge scores (max 5) were significantly higher for HIV providers (2.8 versus 2.2; p < 0.001), age > 41 (mean 2.8 versus 2.3; p = 0.004), White race (2.7 versus 2.2; p = 0.026) and participants in the New York region (3.0 versus 2.3; p < 0.001). In a multivariable model of knowledge scores, all but age remained significant. Among 201 potential prescribers, the rate of prior PrEP prescription was higher among HIV providers than non-HIV providers (34 versus 9 %; p < 0.001) and by knowledge score, but the association with provider status was no longer significant in multivariable analysis that controlled for knowledge. Intent to prescribe PrEP in the future was high for all provider types (64 %) and was associated with knowledge scores in multivariable analysis. The most common concerns about PrEP (>40 % of providers) were drug toxicities, development of resistance and patient adherence to follow-up; 32 % identified risk compensation as a concern. HIV providers had significantly greater PrEP knowledge than non-HIV providers, but differences by provider type in past PrEP prescription were largely dependent on knowledge. Future PrEP prescription was also associated with knowledge, though all providers expressed greater future use. Education of potential PrEP providers will be a key component of successful PrEP implementation.

Health administrative data can be used to define a shared care typology for people with HIV

OBJECTIVES

Building on an existing theoretical shared primary care/specialist care framework to (1) develop a unique typology of care for people living with human immunodeficiency virus (HIV) in Ontario, (2) assess sensitivity of the typology by varying typology definitions, and (3) describe characteristics of typology categories.

STUDY DESIGN AND SETTING

Retrospective population-based observational study from April 1, 2009, to March 31, 2012. A total of 13,480 eligible patients with HIV and receiving publicly funded health care in Ontario. We derived a typology of care by linking patients to usual family physicians and to HIV specialists with five possible patterns of care. Patient and physician characteristics and outpatient visits for HIV-related and non-HIV-related care were used to assess the robustness and characteristics of the typology.

RESULTS

Five possible patterns of care were described as low engagement (8.6%), exclusively primary care (52.7%), family physician-dominated comanagement (10.0%), specialist-dominated comanagement (30.5%), and exclusively specialist care (5.2%). Sensitivity analyses demonstrated robustness of typology assignments. Visit patterns varied in ways that conform to typology assignments.

CONCLUSION

We anticipate this typology can be used to assess the impact of care patterns on the quality of primary care for people living with HIV.

A cross-sectional, population-based study of HIV physicians and outpatient health care use by people with HIV in Ontario

BACKGROUND

People with HIV are living longer and their care has shifted towards the prevention and management of comorbidities. However, little is known about who is providing their care. Our objective was to characterize the provision of HIV care in Ontario by physician specialty.

METHODS

We conducted a retrospective population-based observational study using linked administrative databases in Ontario, Canada, a single payer health care system. All Ontarians with HIV were identified using a validated case ascertainment algorithm. We examined office-based health care visits for this cohort between April 1, 2009 and March 31, 2012. Physician characteristics were compared between specialty groups. We stratified the frequency and distribution of physician care into three categories: (a) care by physician specialty (family physicians, internal medicine specialists, infectious disease specialists, and other specialists), (b) care based on physician caseload (low, medium or high categorized as ≤5, 6-49 or ≥50 HIV patients per physician), and (c) care that is related to HIV versus unrelated to HIV.

RESULTS

Family physicians were older, graduated earlier, were more often female, and were the only group practicing in rural settings. Unlike other specialists, most family physicians (76.8%) had low-volume caseloads. There were 406,411 outpatient visits made by individuals with HIV; one-third were for HIV care. Family physicians provided the majority of care (53.6% of all visits and 53.9% of HIV visits). Internal medicine specialists provided 4.9% of all visits and 9.6% of HIV visits. Infectious disease specialists provided 12.5% of all visits and 32.7% of HIV visits. Other specialties provided 29.0% of visits; most of these (33.0%) were to psychiatrists.

CONCLUSIONS

The distribution of visits to physicians caring for HIV patients reveals different patterns of health care delivery by specialty and HIV caseload. Further research should delineate how specialties share care for this population and how different patterns relate to quality of care.

Frequency and Determinants of Preventive Care Counseling by HIV Medical Care Providers during Encounters with Newly Diagnosed and Established HIV-Infected Patients

This study evaluates the frequency and determinants of preventive care counseling by HIV medical care providers (HMCPs) during encounters with newly diagnosed and established HIV-infected patients. Data used were from a probability sample of HMCPs in Houston/Harris County, Texas, surveyed in 2009. Overall, HMCPs offered more preventive care counseling to newly diagnosed than the established patients (adjusted odds ratio [AOR] = 7.28; 95% confidence interval [CI] = 2.86-16.80). They were more likely to counsel newly diagnosed patients than the established ones on medication and adherence (AOR = 14.70; 95% CI = 1.24-24.94), HIV risk reduction (AOR = 5.91; 95% CI = 0.48-7.13), and disease screening (AOR = 7.20; 95% CI = 0.72-11.81). HIV medical care providers who were less than 45 years of age, infectious disease specialists, and had less than 30 minutes of encounter time were less likely to counsel patients regardless of the status. Our findings suggest the need for HMCPs to improve their preventive care counseling efforts, in order to help patients build skills for adopting and maintaining safe behavior that could assist in reducing the risk of HIV transmission.

A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario

BACKGROUND

As people diagnosed with HIV and receiving combination antiretroviral therapy are now living longer, they are likely to acquire chronic conditions related to normal ageing and the effects of HIV and its treatment. Comordidities for people with HIV have not previously been described from a representative population perspective.

METHODS

We used linked health administrative data from Ontario, Canada. We applied a validated algorithm to identify people with HIV among all residents aged 18 years or older between April 1, 1992 and March 31, 2009. We randomly selected 5 Ontario adults who were not identified with HIV for each person with HIV for comparison. Previously validated case definitions were used to identify persons with mental health disorders and any of the following physical chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end-stage renal failure. We examined multimorbidity prevalence as the presence of at least two physical chronic conditions, or as combined physical-mental health multimorbidity. Direct age-sex standardized rates were calculated for both cohorts for comparison.

RESULTS

34.4% (95% confidence interval (CI) 33.6% to 35.2%) of people with HIV had at least one other physical condition. Prevalence was especially high for mental health conditions (38.6%), hypertension (14.9%) and asthma (12.7%). After accounting for age and sex differences, people with HIV had significantly higher prevalence of all chronic conditions except myocardial infarction and hypertension, as well as substantially higher multimorbidity (prevalence ratio 1.30, 95% CI 1.18 to 1.44) and combined physical-mental health multimorbidity (1.79, 95% CI 1.65 to 1.94). Prevalence of multimorbidity among people with HIV increased with age. The difference in prevalence of multimorbidity between the two cohorts was more pronounced among women.

CONCLUSION

People living with HIV in Ontario, especially women, had higher prevalence of comorbidity and multimorbidity than the general population. Quantifying this morbidity at the population level can help inform healthcare delivery requirements for this complex population.

Prevention counseling practices of HIV care providers with patients new to HIV medical care: medical monitoring project provider survey, 2009

OBJECTIVES

To determine the prevalence of prevention counseling discussions between HIV care providers and their patients who are newly linked to care and to assess factors that facilitate such discussions.

METHODS

In 2009, a probability sample of HIV care providers in 582 outpatient settings in the United States and Puerto Rico was surveyed regarding provider's HIV prevention discussions with HIV-infected patients newly linked to HIV medical care.

RESULTS

A majority of providers reported consistently discussing HIV transmission risk reduction (76%), sexually transmitted disease risk (66%), and adherence to antiretroviral regimens (87%). Only 35% of providers reported consistently discussing partner counseling services.

CONCLUSION

The proportion of providers engaged in HIV prevention counseling with patients newly linked to HIV care is generally high, but more work is needed to encourage providers to fully participate as partners in prevention, which is central to preventing onward transmission of HIV.

Who Provides Primary Care? An Assessment of HIV Patient and Provider Practices and Preferences

Background

Non-AIDS co-morbidities are emerging as the main health problems for those living with HIV, and primary care for this population is an evolving challenge. Recent studies have raised the question of whether specialists or generalists are best suited to provide HIV primary care, but patients’ actual usage patterns and the preferences of patients and providers have not been well studied.

Methods

We anonymously surveyed 98 patients and eight HIV-specialized providers regarding primary care usage patterns and preferences at an academic HIV clinic in Los Angeles that serves insured patients.

Results

Fifty-nine percent of patients use their HIV physician as their primary care provider, and 84% would prefer this model. Physicians were divided on their preferred role, with five out of eight desiring to provide both primary care and HIV care. All eight physicians rated their comfort with antiretroviral therapy and opportunistic infections greater than for non-AIDS co-morbidities. Eighty-one percent of patients and seven of eight providers were supportive of having a co-located primary care physician at the HIV clinic.

Conclusions

We conclude that patients prefer integration of HIV and primary care, but providers have variable desire to serve as primary care physicians and may be uncomfortable with non-AIDS co-morbidities. This raises the need for improved patient-provider communication about primary care needs, and calls for novel ways of systematically providing primary care to HIV-infected patients.

The next therapeutic challenge in HIV: polypharmacy

With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.

Influence of provider experience on antiretroviral adherence and viral suppression

BACKGROUND AND AIM

Early in the combination antiretroviral therapy (cART) era, provider experience (as measured by panel size) was associated with improved outcomes. We explored that association and other characteristics of provider experience.

METHODS

We performed a retrospective cohort analysis in Kaiser Permanente California (an integrated health care system in the United States), examining all human immunodeficiency virus seropositive (HIV+) patients initiating a first cART regimen (antiretroviral therapy [ART]-naïve, N = 7071) or initiating a second or later cART regimen (ART-experienced, N = 3730) from 1996-2006. We measured ART adherence through 12 months (pharmacy fill and refill records) and determined HIV viral load levels below limits of quantification at 12 months. Provider experience, updated annually, was measured as (1) HIV panel size (0-10 patients as reference strata), (2) years treating HIV (less than 1 year as reference), and (3) specialty ( noninfectious disease specialty, non-HIV expert as reference). We assessed associations by utilizing mixed modeling analyses (clustered by provider and medical center), controlling for patient age, sex, race/ethnicity, HIV risk behavior, hepatitis C coinfection, ART regimen class, and calendar year.

RESULTS

Among the ART-experienced, improved adherence was associated with greater years experience (mean increase 3.1% 2-5 years experience; 3.7% 5-10 years; 2.7% 11-20 years; P = 0.07, categorical). In adjusted analyses, viral suppression among ART-naïve was positively associated with panel size (odds ratio 26-50 patients: 1.31, P = 0.03, categorical), but negatively associated with years experience (18% less for greater than 100 patients; P = 0.003). No provider characteristic was significantly associated with improved adherence among ART-naïve or odds of maximal viral suppression among ART-experienced in adjusted analysis.

CONCLUSIONS

Except for panel size and years experience among ART-naïve, provider characteristics did not significantly influence ART adherence or likelihood of viral suppression.

An integrated approach for antiretroviral adherence and secondary HIV transmission risk-reduction support by nurses in Kenya

Ongoing antiretroviral therapy (ART) adherence and secondary HIV transmission-risk reduction (positive prevention) support are needed in resource-limited settings. We evaluated a nurse-delivered counseling intervention in Kenya. We trained 90 nurses on a brief counseling algorithm that comprised ART and sexual-risk assessment, risk-reduction messages, and health-promotion planning. Self-reported measures were assessed before, immediately after, and 2 months post-training. Consistent ART adherence assessment was reported by 29% of nurses at baseline and 66% at 2 months post-training (p < .001). Assessment of patient sexual behaviors was 25% at baseline and 60% at 2 months post-training (p < .001). Nurse practice behaviors recommended in the counseling algorithm improved significantly at 2 months post-training compared with baseline, odds ratios 4.30-10.50. We found that training nurses in clinical counseling for ART adherence and positive prevention is feasible. Future studies should test impact of nurse counseling on patient outcomes in resource-limited settings.

HIV quality of care assessment at an academic hospital: outcomes and lessons learned

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.

An epidemic in evolution: the need for new models of HIV care in the chronic disease era

Since the beginning of the AIDS epidemic, models of HIV care have needed to be invented or modified as the needs of patients and communities evolved. Early in the epidemic, primary care and palliative care predominated; subsequently, the emergence of effective therapy for HIV infection led to further specialization and a focus on increasingly complex antiretroviral therapy as the cornerstone of effective HIV care. Over the past decade, factors including (1) an aging, long-surviving population; (2) multiple co-morbidities; (3) polypharmacy; and (4) the need for chronic disease management have led to a need for further evolution of HIV care models. Moreover, geographic diffusion; persistent disparities in timely HIV diagnosis, treatment access, and outcomes; and the aging of the HIV provider workforce also suggest the importance of reincorporating primary care providers into the spectrum of HIV care in the current era. Although some HIV-dedicated treatment centers offer comprehensive medical services, other models of HIV care potentially exist and should be developed and evaluated. In particular, primary care- and community-based collaborative practices-where HIV experts or specialists are incorporated into existing health centers-are one approach that combines the benefits of HIV-specific expertise and comprehensive primary care using an integrated, patient-centered approach.

Prevention counseling for HIV-infected persons: what every clinician needs to know

The absence of adequate and regular prevention counseling during routine clinical encounters translates into missed opportunities for HIV prevention. HIV care providers have considerably more contact with patients than clinicians in other disciplines. These contacts should be translated into opportunities to provide HIV prevention messages to patients and should be a priority for all clinicians caring for HIV-positive patients. Coincidental preventive care for HIV-positive patients is inherently unproductive because of the absence of reinforcing messages. In a recent meta-analysis, HIV-positive individuals who underwent counseling and testing services reduced high-risk behaviors by about 68%. Prevention counseling should focus on positive reinforcement, harm reduction, education, and support. We strongly recommend regular, brief, targeted prevention counseling as a part of every clinical encounter.

Emerging issues in management of sexually transmitted diseases in HIV infection

Sexually transmitted diseases (STDs) occur often among sexually active persons with HIV infection. Incident STDs may complicate the course of HIV infection and potentiate HIV transmission in the coinfected individual by mucosal disruption and an increase in HIV concentration in ulcers and involved mucous membranes. Conducting ongoing periodic sexual risk assessments in HIV-positive patients in routine medical care is critical to identifying asymptomatic infections. HIV clinicians should be familiar with updated recommendations for screening, diagnosis, and treatment of bacterial and viral STDs, including those specific to HIV infection. This article addresses emerging issues in the management of STDs in HIV-infected persons and summarizes the latest evidence that can be applied to clinical decision-making in this population.

Implementing packaged HIV-prevention interventions for HIV-positive individuals: considerations for clinic-based and community-based interventions

Providing efficacious human immunodeficiency virus (HIV) prevention services to HIV-positive individuals is an appropriate strategy to reduce new infections. The Centers for Disease Control and Prevention (CDC) has identified interventions with evidence of efficacy for prevention with positives (PwP). Through its process of disseminating evidence-based interventions (EBIs), CDC has attempted to diffuse four of these interventions into practice. One of these interventions has been diffused to community-based organizations, whereas another has been diffused to medical clinics serving HIV-positive people. A third intervention was originally developed with HIV-positive individuals using methadone, but uptake by methadone clinics has not occurred. A fourth intervention for HIV-positive adolescents and young adults has had disappointing adoption levels. Unique implementation challenges have been encountered in various intervention settings. Lessons learned in the dissemination of the first four PwP interventions will facilitate implementation of three new PwP EBIs currently being packaged for dissemination.

HIV-positive patients' discussion of oral health with their HIV primary care providers in Miami, Florida

Over 90% of HIV-positive persons will have at least one oral manifestation of HIV disease during the course of infection. Clinical guidelines suggest that examination of the oral cavity should be included in initial and interim physical examinations of all HIV-infected patients by their HIV care providers. Clinically significant manifestations of oral disease may impact prescribed treatment regimens. The objective of this analysis was to describe HIV-positive patients' discussion of oral health and dental health with their HIV primary care providers and the correlates of this discussion. We used cross-sectional data from the baseline of a randomized trial testing the efficacy of a risk reduction intervention. Participants were HIV-positive male and female patients attending five HIV primary care clinics in Miami-Dade County, Florida, USA. Overall, 37% of patients did not discuss oral health with their provider. After controlling for age, gender, education, and clinic, odds of discussion of oral health for respondents with five or more primary care visits in the past year were half the odds of those with fewer visits (odds ratio (OR)=0.525, 95% confidence interval (CI): 0.336, 0.821). Odds of discussion for men reporting illicit drug use were 35% of that for non-drug using men (OR=0.353, 95% CI: 0.186, 0.671). Odds of discussion were 1.4 times greater for each additional health topic discussed (e.g., nutrition and smoking) (95% CI: 1.317, 1.544). Given that more than one-third of patients reported no discussion of oral health with HIV primary care providers in the past year, there is a need to increase the focus on oral health in the HIV primary care setting.

Frequency of discussing HIV prevention and care topics with patients with HIV: influence of physician gender, race/ethnicity, and practice characteristics

BACKGROUND

Because people living with HIV now have greater life expectancy and reduced morbidity, there is a greater need for physicians to discuss HIV transmission risk reduction with these patients. Very limited data are available examining how frequently this discussion is held.

OBJECTIVE

We examined the frequency of discussing HIV prevention and HIV care topics, as well as the associations of gender, race/ethnicity, and practice characteristics of physicians caring for persons with HIV.

METHODS

In a 4-city (Miami, Atlanta, Baltimore, Los Angeles) survey, 417 licensed physicians who primarily cared for patients with HIV were mailed a 58-item questionnaire about how frequently they discussed HIV transmission risk reduction, adherence to HIV antiretroviral treatment (ART), adherence to opportunistic infection (OI) prophylaxis, and how to take medicines. Multivariate logistic regression analyses were used to examine the association between physician gender, race/ethnicity, and practice characteristics, and the frequency of discussing these topics.

RESULTS

A total of 317 physicians responded to the mailed questionnaire. Less than 40% of the physicians reported always discussing HIV transmission risk reduction with patients. In contrast, 83.9% and 65.0% reported always discussing adherence to ART and to OI prophylaxis, respectively. Of these physicians, 65.1% strongly agreed or somewhat agreed that they had sufficient time to provide the care and information needed to their patients. In multivariate analysis, the frequency of discussing HIV transmission risk reduction was higher for physicians who were Hispanic (P = 0.03) or Asian/Pacific Islander (P = 0.001), for physicians who reported they had enough time to provide care and information to patients (P = 0.003), and for physicians who cared for fewer patients (P = 0.05). The frequency of discussing HIV transmission risk reduction was suggestive of a higher rate for female physicians, but did not quite reach statistical significance.

CONCLUSIONS

We observed a lower frequency of discussing the topic of HIV prevention compared with that of HIV care among the physicians surveyed. This infrequent discussion with patients with HIV represents a missed opportunity, and physicians should be encouraged to include discussion of prevention as a standard of care.

Translating concern into action: HIV care providers' views on counseling patients about HIV prevention in the clinical setting

Recent Centers for Disease Control (CDC) guidelines recommend that HIV care practitioners provide HIV prevention counseling to patients at routine medical visits. However, research shows that HIV care practitioners provide such counseling infrequently, presenting a challenge for clinics implementing these guidelines. Our qualitative study of 19 HIV care providers at an infectious diseases clinic in the southeastern US explored providers' beliefs about their patients' HIV transmission behaviors, expected outcomes of conducting HIV prevention counseling, and perceived barriers and facilitators to counseling. Providers' concern about HIV transmission among their patients was high but did not "translate into action" in the form of counseling. They anticipated poor outcomes from counseling, including harm to patient-provider relationships, and failure of patients to change their behavior. They also listed barriers and facilitators to counseling, most importantly time, state reporting policies, and conversational triggers. Implications for implementation of CDC guidelines and clinic-based "Prevention with Positives" programs are discussed.

Is AIDS chronic or terminal? The perceptions of persons living with AIDS and their informal support partners

Viewed as a terminal disease just a decade ago, HIV/AIDS is now often characterized as a chronic yet manageable disease. The goal of this study is to assess the perceptions of the course of the disease among persons living with AIDS and their informal support partners and to identify the themes that distinguish the differing perceptions of the epidemic. The findings from this research reveal that 41% of persons living with AIDS and 39% of their informal support partners perceive AIDS as chronic. By contrast, 37% of persons living with AIDS and 39% of the informal support partners perceive AIDS to be terminal rather than chronic. Among persons living with HIV/AIDS, those with lower levels of education and higher levels of perceived race-based discrimination were significantly more likely to view AIDS as a terminal rather than chronic condition. In addition, informal support partners in poor health were significantly more likely than others to view AIDS as terminal rather than chronic. Content analyses of the qualitative data revealed five broad themes related to the specific perceptions of AIDS, including medications, personal experience, cure, time/eventuality and education. The implications of these findings are discussed.

Prevention with HIV-infected men: recommendations for practice and research

In the United States in 2004, 74% of the new AIDS cases and 70% of the new HIV cases were in men; in addition, 75% of the cases of HIV in women were classified as heterosexually acquired. These numbers make it clear that expanded prevention efforts for men who are infected with HIV would make a large contribution to containing the epidemic. This report explores epidemiologic and psychosocial issues related to prevention in men with HIV and compares how those variables relate to prevention efforts. The report ends with a discussion of a method to approach HIV risk reduction in clinical care settings.

Providers' HIV prevention discussions with HIV-seropositive injection drug users

Public health agencies have recommended incorporating HIV prevention counseling into the medical care of persons living with HIV/AIDS. Injection drug users (IDUs) especially need HIV risk-reduction counseling because of their high risk for HIV transmission through both sexual and injection behaviors. The objective of this study was to assess the prevalence of, and patient factors associated with, the delivery of HIV prevention messages to HIV-seropositive IDUs in primary care settings. A majority of participants reported having an HIV prevention discussion with their provider during their most recent primary care visit. Factors significantly associated with report of such discussion were being Hispanic or non-Hispanic Black; high school education or less; and better perception of engagement with provider. Medical providers should provide prevention messages to all HIV-seropositive IDUs, regardless of demographic factors. Effective HIV prevention interventions in primary care settings, including interventions to improve patient-provider communication, are needed for HIV-seropositive IDUs.

Activities to increase provider awareness of early syphilis in men who have sex with men in 8 cities, 2000-2004

OBJECTIVE

Describe provider awareness campaigns undertaken in response to syphilis epidemics among men who have sex with men (MSM).

METHODS

Descriptive data from 8 cities facing MSM syphilis epidemics was compiled.

RESULTS

Provider awareness efforts included medical alerts, provider visits, lectures to providers on symptom recognition and treatment, and ongoing provision of syphilis and other sexually transmitted diseases (STD) morbidity information through mailings, visits, and e-mail communications. Increases in private provider reporting of syphilis cases followed provider visits in Atlanta and overall provider education efforts in New York City. Decreases in reporting delays and increases in physician calls to the STD program were reported in San Francisco following provider syphilis lectures. Increases in provider participation in community action meetings followed provider awareness efforts in Houston, Chicago, and Miami.

CONCLUSIONS

Various methods were used to increase provider awareness of syphilis in these 8 cities. The cost and impact of these activities merits more formal evaluation to determine their contribution to syphilis control in MSM.

Sexually transmitted disease testing protocols, sexually transmitted disease testing, and discussion of sexual behaviors in HIV clinics in Los Angeles County

OBJECTIVE/GOAL

The objective of this study was to evaluate the use of written protocols for sexually transmitted disease (STD) screening, the frequency and types of STD tests performed, and the occurrence and frequency of obtaining sexual risk assessments among HIV clinics.

STUDY

A survey was administered to 36 medical directors, clinic directors, and HIV providers representing 48 HIV healthcare clinics in Los Angeles.

RESULTS

The use of a written or electronic protocol for STD testing was reported by 50% of clinics. Clinics with written or electronic STD protocols were significantly more likely to report questioning patients at each visit regarding their sexual practices (prevalence ratio, 2.2; 95% confidence interval, 1.4-3.4). Clinics with written or electronic protocols were not more likely to report more frequent STD testing.

CONCLUSIONS

Written or electronic protocols for STD testing may promote sexual risk assessment questioning among HIV healthcare providers and may help to ensure STD testing per Centers for Disease Control and Prevention/IDSA guidelines for HIV-positive persons at sexual risk.

Differences between infectious diseases-certified physicians and general medicine-certified physicians in the level of comfort with providing primary care to patients

BACKGROUND

Human immunodeficiency virus (HIV)-related mortality has decreased because of highly active antiretroviral therapy. As the life expectancy of HIV-infected patients has increased, the management of comorbid disease in such patients has become a more important concern. We examined the level of comfort self-reported by experts in HIV medicine with prescribing medications to HIV-infected patients for hyperlipidemia, diabetes, hypertension, and depression.

METHODS

As part of a larger project (the Veterans Aging Cohort Study), physicians at infectious diseases (ID) clinics and physicians at general medical (GM) clinics were asked to complete a survey requesting information about demographic characteristics, training and certification received, and self-reported comfort with prescribing medications for patients with hyperlipidemia, diabetes, hypertension, and/or depression. Comfort was rated using a 5-point Likert scale, with scores of 4-5 classified as "comfortable."

RESULTS

Of 150 attending physicians surveyed, 51 (34%) were ID certified, 33 (22%) were GM certified but practicing at an ID clinic, and 66 were GM certified and practicing at a GM clinic. Comorbid conditions were common among HIV-infected patients treated at the ID clinics (22% of these patients had hyperlipidemia, 17% had diabetes, 40% had hypertension, and 27% had depression). However, comfort with treating these conditions was less among physicians at the ID clinic. For example, comfort treating patients with hyperlipidemia was greater for GM-certified physicians at GM clinics than for GM-certified physicians and ID-certified physicians at ID clinics (98% vs. 73% and 71%, respectively; P < .0001 for trend). A similar pattern was seen for treating patients with diabetes and hypertension (P < .0001). Comfort with treating patients with depression was generally lower, particularly among physicians at ID clinics (P < .0001).

CONCLUSIONS

We found that ID-certified physicians and GM-certified physicians at ID clinics reported less comfort prescribing medications for common comorbid conditions, compared with generalist physicians at GM clinics, despite a substantial prevalence of these conditions at the ID clinics. Methods are needed to increase physicians' level of comfort for prescribing treatment and/or to facilitate referral to other physicians for treatment.

HIV/AIDS: a minority health issue

HIV infection among racial and ethnic minorities is an ongoing health crisis. The disproportionate impact of HIV infection on racial and ethnic minorities has affected communities already struggling with many social and economic challenges, such as poverty, substance abuse, homelessness,unequal access to health care, and unequal treatment once in the health care system. Superimposed on these challenges is HIV infection, the transmission of which is facilitated by many of these factors. Although the epidemic is disproportionately affecting all racial and ethnic minorities, within these minority populations women are particularly affected. The care and management of racial and ethnic minorities who have HIV infection has been complicated by the unequal access to health care and the unequal treatment once enrolled in health care. Health insurance status, lack of concordance between the race of the patient and the provider, and satisfaction with the quality of their care all impact on treatment outcomes in this population. In addition, the provider must be aware of the many comorbid conditions that may affect the delivery of care to minority patients living with HIV infection: depression, substance and alcohol abuse, and posttraumatic stress disorders. The impact of these comorbid conditions on the therapeutic relationship, including treatment and adherence, warrants screening for these disorders and treating them when identified. Because the patient provider relationship has been repeatedly identified as a predictor of higher adherence, developing and maintaining a strong therapeutic alliance is critical. Participation of racial and ethnic minorities in HIV clinical trials, as in other disease states, has been very poor. Racial and ethnic minorities have been chronically underrepresented in HIV clinical trials, despite their overrepresentation in the HIV epidemiology. This underrepresentation seems to be the result of a combination of factors including (1) provider bias in referring to clinical trials, (2) mistrust of clinical research, (3) past poor experience with the health care system, and (4) the conspiracy theories of HIV disease. The paucity of minority health care professionals and minority investigators in HIV research further affects minority participation in clinical research. To improve racial and ethnic minority participation in clinical trials a sustained effort is necessary at multiple levels. Increased recruitment and retention is an ongoing need, and one that will not be satisfactorily addressed until there are better community-academic and research partner-ships, and the research questions posed also address issues of concern and significance to the affected community. Reduction in barriers to participation in clinical trials, especially given the many competing needs of racial and ethnic minority patients, is also needed. Multidisciplinary HIV care teams and research staff with training in cultural competency and cultural sensitivity may also be helpful. Prevention of HIV infection remains essential, especially among those seeking care for HIV infection. Despite several published recommendations for the inclusion of HIV prevention in the clinical care setting, studies have documented how few providers actually achieve this goal, especially those who care for disadvantaged patients. Although there are many barriers to discussing HIV risk behaviors and prevention strategies in an office visit,including time constraints and potential provider discomfort in discussing these matters, clinical visits represent an important opportunity to reinforce HIV prevention and possibly decrease further HIV transmission.

Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities

OBJECTIVES

We investigated physicians' delivery of HIV prevention counseling to newly diagnosed and established HIV-positive patients.

METHODS

A questionnaire was developed and mailed to 417 HIV physicians in 4 US cities.

RESULTS

Overall, rates of counseling on the part of physicians were low. Physicians reported counseling newly diagnosed patients more than established patients. Factors associated with increased counseling included having sufficient time with patients and familiarity with treatment guidelines. Physicians who perceived their patients to have mental health and substance abuse problems, who served more male patients, and who were infectious disease specialists were less likely to counsel patients.

CONCLUSIONS

Intervention strategies with physicians should be developed to overcome barriers to providing counseling to HIV-positive patients.