Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States

Emotional Communication in HIV Care: An Observational Study of Patients' Expressed Emotions and Clinician Response

Emotional support is essential to good communication, yet clinicians often miss opportunities to provide empathy to patients. Our study explores the nature of emotional expressions found among patients new to HIV care, how HIV clinicians respond to these expressions, and predictors of clinician responses. Patient-provider encounters were audio-recorded, transcribed, and coded using the VR-CoDES. We categorized patient emotional expressions by intensity (subtle 'cues' vs. more explicit 'concerns'), timing (initial vs. subsequent), and content (medical vs. non-medical). Emotional communication was present in 65 of 91 encounters. Clinicians were more likely to focus specifically on patient emotion for concerns versus cues (OR 4.55; 95% CI 1.36, 15.20). Clinicians were less likely to provide space when emotional expressions were repeated (OR 0.32; 95% CI 0.14, 0.77), medically-related (OR 0.36; 95% CI 0.17, 0.77), and from African American patients (OR 0.42; 95% CI 0.21, 0.84). Potential areas for quality improvement include raising clinician awareness of subtle emotional expressions, the emotional content of medically-related issues, and racial differences in clinician response.

Incidence of disseminated Mycobacterium avium-complex infection in HIV patients receiving antiretroviral therapy with use of Mycobacterium avium-complex prophylaxis

The incidence of disseminated Mycobacterium avium complex (MAC) infection in HIV patients has fallen markedly since the introduction of effective antiretroviral therapy (ART). However, current guidelines still recommend primary prophylaxis. We conducted a retrospective cohort study in a university-affiliated hospital from January 1998 to January 2014. During that period, HIV patients who had at least one CD4 cell count below 50 cells/mm³ and had been treated with ART were enrolled. We compared incidence of disseminated MAC infection in the 12 months after the first CD4 cell count below 50 cells/mm³ between prophylaxis and nonprophylaxis groups. A total of 157 patients were enrolled and the total observation period was 144 patient-years (PY). Thirty-three patients (21%) received primary MAC prophylaxis. The initial CD4 cell count of the prophylaxis group was lower than that of the nonprophylaxis group ( P = 0.024), but the proportion of patients who reached a CD4 cell count >100 cells/mm³ ( P = 0.234) and were virologically suppressed ( P = 0.513) 12 months after ART commencement was not different in the prophylaxis and nonprophylaxis groups. The incidence of MAC did not differ significantly between the groups (3.4/100 PY versus 0.8/100 PY, P = 0.368). Routine MAC prophylaxis may be not required in the era of effective ART.

The Global HIV/AIDS Epidemic and Related Mental Health Issues: The Crisis for Africans and Black Americans

HIV/AIDS is one of the most devastating diseases that humanity has ever faced. Since the first clinical evidence of HIV/AIDS was reported in 1981, more than 60 million people have been infected with the virus and more than 20 million have died of AIDS. This article provides an overview of the global HIV/AIDS epidemic with a focus on its impact on sub-Saharan Africa and people of African descent in the United States.

Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity

Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.

The state of disparities in opportunistic infection prophylaxis for blacks with HIV/AIDS

OBJECTIVES

The purpose of this review is to identify and analyze published studies that have evaluated disparities for opportunistic infection (OI) prophylaxis between blacks and whites with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in the United States.

METHODS

The authors conducted a web-based search of MEDLINE (1950-2009) to identify original research articles evaluating the use of OI prophylaxis between blacks and whites with HIV/AIDS. The search was conducted utilizing the following MeSH headings and search terms alone and in combination: HIV, AIDS, Black, race, ethnicity, disparities, differences, access, opportunistic infection, and prophylaxis. The search was then expanded to include any relevant articles from the referenced citations of the articles that were retrieved from the initial search strategy. Of the 29 articles retrieved from the literature search, 19 articles were excluded.

RESULTS

Ten publications met inclusion criteria, collectively published between 1991 and 2005. The collective time periods of these studies spanned from 1987 to 2001. Four studies identified a race-based disparity in that blacks were less likely than whites to use OI prophylaxis, whereas 5 studies failed to identify such a relationship between race and OI prophylaxis. One study identified disparities for Mycobacterium avium complex prophylaxis, but not for Pneumocystis jiroveci pneumonia prophylaxis.

CONCLUSIONS

The evidence regarding race-based disparities in OI prophylaxis is inconclusive. Additional research is warranted to explore potential race-based disparities in OI prophylaxis.

The association of visit length and measures of patient-centered communication in HIV care: a mixed methods study

OBJECTIVE

Patient centered clinical communication may be associated with longer encounters.

METHODS

We used the General Medical Interaction Analysis System (GMIAS) to code transcripts of routine outpatient visits in HIV care, and create 5 measures of patient-centeredness. We defined visit length as number of utterances. To better understand properties of encounters reflected in these measures, we conducted a qualitative analysis of the 15 longest and 15 shortest visits.

RESULTS

All 5 measures were significantly associated with visit length (p<0.05, rank order correlations 0.21-0.44). In multivariate regressions, association of patient centeredness with visit length was attenuated for 4 measures, and increased for 1; two were no longer statistically significant (p>0.05). Black and Hispanic race were associated with shorter visits compared with White race. Some of the longest visits featured content that could be considered extraneous to appropriate care.

CONCLUSION

Patient centeredness is weakly related to visit length, but may reflect inefficient use of time in long encounters.

PRACTICE IMPLICATIONS

Efforts to make visits more patient centered should focus on improving dialogue quality and efficient use of time, not on making visits longer. Shorter visits for Black and Hispanic patients could contribute to health disparities related to race and ethnicity.

HIV-related medical service use by rural/urban residents: a multistate perspective

OBJECTIVE

Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites.

METHODS

Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000-100,000), and urban (>100,000). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS-defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage, and virologic suppression were compared among patients, using χ(2) tests for categorical variables, t-tests for means, and logistic regression for HAART utilization.

RESULTS

HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage, or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have four or more annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis.

CONCLUSION

Although demographic and health care utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and injection drug users.

Patient-provider communication differs for black compared to white HIV-infected patients

Poor patient-provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient-provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient-provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients' talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers' communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient-provider relationships, self-management, and outcomes among black people living with HIV/AIDS.

Impact of patient race on patient experiences of access and communication in HIV care

BACKGROUND

Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes.

OBJECTIVE

To explore associations between race and HIV-infected patients' experiences of access and communication.

DESIGN

This was a cross-sectional survey.

PARTICIPANTS

Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics.

MEASUREMENTS

Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions.

RESULTS

Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication.

CONCLUSIONS

We observed racial disparities in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions.

The effect of care team composition on the quality of HIV care

Compared to single-clinician care, care provided by multiple clinicians might result in higher-quality care, especially if some of them have condition-specific expertise and complementary knowledge, skills, and roles. Individual physician continuity, which has been shown to be associated with care quality, necessarily decreases when care is provided by multiple clinicians. This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. In adjusted analyses, care teams composed of three or more clinicians were associated with more consistent prescribing of pneumocystis carinii pneumonia prophylaxis when medically indicated ( p < .01). Patients with multiple physicians generally reported worse care coordination, however, and had more inappropriate use of emergency services. These findings indicate both advantages and disadvantages to having multiple clinicians. More effort should be devoted to facilitating coordination when multiple clinicians provide care.

Prophylaxis against Pneumocystis pneumonia in patients with inflammatory bowel disease: toward a standard of care

Patients with Crohn's Disease and ulcerative colitis are increasingly treated with a host of immunomodulatory and immunosuppressive medications, including thiopurines and antibody-based biologic agents. Despite the known infectious complications associated with these therapies from the HIV and solid organ transplant literature, there are currently no well-defined concise guidelines to assist gastroenterologists and other physicians in the utility and indication for prophylaxis against Pneumocystis pneumonia and other infections in inflammatory bowel disease (IBD) patients. In this article, we discuss the evidence of various infections associated with immunocompromise in HIV/AIDS, organ transplantation, and in other immunocompromised states, and discuss the evidence for the efficacy and safety of various infectious prophylaxis protocols. In addition, we discuss the evidence for Pneumocystis and other infections in IBD patients treated with corticosteroids, azathioprine/6-MP, biologic agents and other therapies, and we present the case for various antibiotic (and antiviral) regimens to prevent such infections. Based on the review of the literature, this discussion represents a true call for guidelines for infection prophylaxis, to help guide gastroenterologists and all practitioners who care for the challenging population of IBD patients.

Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors

OBJECTIVE

We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients.

DESIGN

We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region.

RESULTS

Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52).

CONCLUSIONS

Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

High rates of primary Mycobacterium avium complex and Pneumocystis jiroveci prophylaxis in the United States

BACKGROUND

National data from the mid-1990s demonstrated that many eligible patients with HIV infection do not receive prophylaxis for opportunistic infections (OIs) and that racial and gender disparities existed in OI prophylaxis receipt.

OBJECTIVE

We examined whether demographic disparities in use of OI prophylaxis persist in 2001 and if outpatient care is associated with OI prophylaxis utilization.

RESEARCH DESIGN

Demographic, clinical, and pharmacy utilization data were collected from 10 U.S. HIV primary care sites in the HIV Research Network.

SUBJECTS

This study consisted of adult patients (>or=18 years old) in longitudinal HIV primary care.

MEASURES

Indications for Pneumocystis jiroveci pneumonia (PCP) or Mycobacterium avium complex (MAC) prophylaxis were 2 or more CD4 counts less than 200 or 50 cells/mm(3) during calendar year (CY) 2001, respectively. Using multivariate logistic regression, we examined demographic and clinical characteristics associated with receipt of PCP or MAC prophylaxis and the association of outpatient utilization with appropriate OI prophylaxis.

RESULTS

Among eligible patients, 88.1% received PCP prophylaxis and 87.6% received MAC prophylaxis. Approximately 80% had 4 or more outpatient visits during CY 2001. Adjusting for care site, male gender (odds ratio [OR], 1.47), Medicare coverage (OR, 1.60), and having 4 or more outpatient visits in a year (OR, 2.34) were significantly associated with increased likelihood of PCP prophylaxis. Adjusting for care site, having 4 or more outpatient visits in a year (OR, 1.85) was associated with increased likelihood of receipt of MAC prophylaxis. There were no demographic or insurance characteristics associated with receipt of MAC prophylaxis.

CONCLUSIONS

The overall prevalence of OI prophylaxis has increased since the mid-1990s, and previous racial and HIV risk factor disparities in receipt of OI prophylaxis have waned. Integration into the healthcare system is an important correlate of receiving OI prophylaxis.

Racial and ethnic disparities in access to physicians with HIV-related expertise

OBJECTIVE

Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise.

DESIGN, SETTING, AND PARTICIPANTS

We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply.

RESULTS

Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50).

CONCLUSIONS

Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.

Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors?

BACKGROUND

Compared to whites, African Americans have been found to have greater morbidity and mortality from HIV, partly due to their lower use of effective antiretroviral therapy. Why racial disparities in antiretroviral use exist is not completely understood. We examined whether racial concordance (patients and providers having the same race) affects the time of receipt of protease inhibitors.

METHODS

We analyzed data from a prospective, cohort study of a national probability sample of 1,241 adults receiving HIV care with linked data from 287 providers. We examined the association between patient-provider racial concordance and time from when the Food and Drug Administration approved the first protease inhibitor to the time when patients first received a protease inhibitor.

RESULTS

In our unadjusted model, white patients received protease inhibitors much earlier than African-American patients (median 277 days compared to 439 days; P < .0001). Adjusting for patient characteristics only, African-American patients with white providers received protease inhibitors significantly later than African-American patients with African-American providers (median 461 days vs. 342 days respectively; P < .001) and white patients with white providers (median 461 vs. 353 days respectively; P= .002). In this model, no difference was found between African-American patients with African-American providers and white patients with white providers (342 vs. 353 days respectively; P > .20). Adjusting for patients' trust in providers, as well as other patient and provider characteristics in subsequent models, did not account for these differences.

CONCLUSION

Patient-provider racial concordance was associated with time to receipt of protease inhibitor therapy for persons with HIV. Racial concordance should be addressed in programs, policies, and future racial and ethnic health disparity research.

HIV Health Care Services For Mexican Migrants

This article reviews the literature on HIV/AIDS health care services for Mexican migrants in the United States. Because so little research has been conducted on Mexican migrants per se, we include literature on Latinos/Hispanics in the United States, because some characteristics may be shared. Furthermore, we focus special attention on data from California because it is on the front line of issues regarding health care for Mexican migrants. The types of health care services needed to improve on the quality of care provided to Mexican migrants living with HIV are highlighted, and recommendations are made for future interventions, research, and binational collaborations.

Polypharmacy in HIV: impact of data source and gender on reported drug utilization

Drug use in HIV is complex and may involve multiple therapeutic and nontherapeutic agents including prescription, over-the-counter, complementary and alternative medicine, and social/recreational drugs. This study was designed to assess the extent of such drug use in HIV-infected men and women. One hundred four adults were recruited through the HIV Ontario Observational Database from HIV outpatient clinics throughout Ontario, Canada. Patient demographics and data on drug use and physician awareness of drug use were collected through in-person interviews and medical chart review. All patient interviews and 96% of medical charts revealed the use of at least one drug. Eighty-five percent of patients reported use of antiretroviral medications; nearly 70% used highly active antiretroviral therapy. Patients used significantly more drugs by patient report (15.7 +/- 7.7) than by medical chart review (8.4 +/- 5.0) reporting up to 39 drugs per person. Pill burden was substantial, averaging 20.7 +/- 12.5 and ranged up to 69 "pills-per-day." Patient-reported physician awareness of drug use was highest for prescription drugs and lowest for social/recreational drugs; correspondingly agreement between medical chart and patient report ranged from 80% for antiretrovirals to 10% for non-prescribed drugs. The drug and pill burden faced by patients with HIV is considerable. Prevalence of use for specific drug classes varied with both data source and gender while number of drugs used differed only by data source. Our findings emphasize the complexity of pharmacotherapy in HIV and the need for comprehensive drug assessment, particularly because of the risks of drug-drug interactions and decreased adherence secondary to therapeutic complexity.

Disseminated mycobacterium avium-intracellulare complex (MAC) infection in the era of effective antiretroviral therapy: is prophylaxis still indicated?

Before highly active antiretroviral therapies (HAART) were available for the treatment of persons with HIV infection, disseminated Mycobacterium avium-intracellulare complex (MAC) infection was one of the most common opportunistic infections that affected people living with AIDS. Routine use of chemoprophylaxis with a macrolide has been advocated in guidelines for the treatment of HIV-infected individuals if they have a circulating CD4+ cell count of < or =50 cells/microL. In addition, lifelong prophylaxis for disease recurrence has been recommended for those with a history of disseminated MAC infection. The introduction of HAART has resulted in a remarkable decline in the incidence of opportunistic infections and death among persons living with AIDS. Considerable reconstitution of functional immune responses against opportunistic infections can be achieved with HAART. In the case of infection with MAC, there has been a substantial reduction in the incidence of disseminated infections in the HAART era, even in countries where the use of MAC prophylaxis was never widely accepted. Moreover, the clinical picture of MAC infections in patients treated with potent antiretroviral therapies has shifted from a disseminated disease with bacteraemia to a localised infection, presenting most often with lymphadenopathy and osteomyelitis. Data from several recently conducted randomised, double-blind, placebo-controlled trials led to the current practice of discontinuing primary and secondary prophylaxis against disseminated MAC infections at stable CD4+ cell counts >100 cells/microL. These recommendations are still conservative as primary or secondary disseminated MAC infections are only rarely seen in patients who respond to HAART, despite treatment initiation at very low CD4+ cell counts. Potential adverse effects of macrolide therapy and drug interactions with antiretrovirals also metabolised via the cytochrome P450 enzyme system must be critically weighed against the marginal benefit that MAC prophylaxis may provide in addition to treatment with HAART. These authors feel that, unless patients who initiate HAART at low CD4+ cell counts do not respond to HIV-treatment, routine MAC prophylaxis should not be recommended. Nevertheless, the patient population for whom MAC prophylaxis may still be indicated in the era of HAART needs to be identified in prospectively designed clinical trials.

The quality of health care delivered to adults in the United States

BACKGROUND

We have little systematic information about the extent to which standard processes involved in health care--a key element of quality--are delivered in the United States.

METHODS

We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores.

RESULTS

Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence.

CONCLUSIONS

The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.

HIV-related pulmonary infections: a review of the recent literature

Antimicrobial prophylaxis and highly active antiretroviral therapy have changed the epidemiology and impact of pulmonary infection in patients infected with the human immunodeficiency virus (HIV). However, pulmonary infection remains a significant contributor to the morbidity and mortality of such patients. Bacterial pneumonia and tuberculosis remain common lung infections in this setting, especially where appropriate prophylaxis is unavailable or when compliance with such therapy is poor. Pneumonia related to Pneumocystis carinii also remains a significant problem, especially as a presenting illness in patients not yet known to be infected with HIV. Recrudescence of "treated" infection as a manifestation of the immune reconstitution syndrome may become more commonly encountered as more patients are treated with highly active therapy.

Electronic human immunodeficiency virus (HIV) clinical reminder system improves adherence to practice guidelines among the University of Washington HIV Study Cohort

We conducted a prospective study of an electronic clinical reminder system in an academic medical center-based human immunodeficiency virus (HIV) specialty clinic. Published performance indicators were used to examine adherence to HIV practice guidelines before and after its implementation for 1204 patients. More than 90% of patients received CD4 cell count and HIV type 1 (HIV-1) RNA level monitoring every 3-6 months during both time periods, and approximately 80% of patients with a CD4 cell count nadir of <350 cells/mm(3) received highly active antiretroviral therapy. Patients were significantly more likely to receive prophylaxis against Mycobacterium avium complex (hazard ratio, 3.84; 95% confidence interval [CI], 1.58-9.31; P=.003), to undergo annual cervical carcinoma screening (OR, 2.09; 95% CI, 1.04-4.16; P=.04), and to undergo serological screening for Toxoplasma gondii (odds ratio [OR], 1.86; 95% CI, 1.05-3.27; P=.03) and syphilis infection (OR, 3.71; 95% CI, 2.37-5.81; P<.0001). HIV clinical reminders delivered at the time that HIV care is provided were associated with more timely initiation of recommended practices.