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

Structural Barriers to Primary Care Among Sex Workers: Findings from a Community- Based Cohort in Vancouver, Canada (2014-2021)

Background

Due to structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers' broader primary healthcare access, we aimed to examine structural factors associated with primary care access among sex workers over a 7-year period.

Methods

Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders.

Results

Amongst 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced access to primary care (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49 - 0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51 - 1.14).

Conclusions

This study characterized primary care access and its structural determinants among sex workers over 7-years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care access. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.

Determinants of access to general practice in a shared care model for people living with HIV: a qualitive study of patients' perspectives in an Australian rural community

BACKGROUND

Improved management of human immunodeficiency virus (HIV) has resulted in improved life expectancy for people living with HIV and an ageing population with a significant comorbidity burden. Shared care models, involving the co-ordinated liaison between general practitioners and specialist physicians, have been advocated for in Australia to provide comprehensive care. People living with HIV in rural areas have reduced access to general practice and therefore shared care. This study explores the perspectives of people living with HIV on the barriers and enablers to accessing shared care in an Australian rural setting.

METHODS

In this qualitative study, semi-structured interviews were conducted with adults living with HIV who either resided in or accessed care in a rural area of Australia. Interviews were conducted via video conferencing, phone or face-to-face. Transcripts were imported into NVivo, coded and analysed in alignment with a conceptual framework of healthcare access defined by Levesque and colleagues.

RESULTS

Thirteen interviews were conducted in total. Participants' narratives demonstrated the substantial influence of accessibility to general practice on their ability to engage in effective shared care. Challenges included the perception that general practitioners would not provide additive value to participants' care, which restricted the ability to both seek and engage in the shared care model. Healthcare beliefs, expectations and experiences with stigma led participants to prioritise the perceived interpersonal qualities of specialist care above a shared care system. Access to shared care was facilitated by continuity of care in general practice but logistical factors such as affordability, transport and availability impacted the ability to access regular high-quality healthcare.

CONCLUSIONS

Navigating patient priorities and anticipated stigma in general practice within the resource limitations of rural healthcare were barriers to effective shared care. General practitioners' ability to build rapport and long-term relationships with participants was instrumental in the perception of valuable care. Strategies are required to secure continuity of care with interpersonally skilled general practitioners to ensure provision of quality primary care for people living with HIV, which can be supported by specialist physicians in a shared care model.

Self-sampled specimens demonstrate comparable accuracy and consistency to clinician-sampled specimens for HPV detection among men who have sex with men in China

OBJECTIVES

Despite a high risk of human papillomavirus (HPV) infection among men who have sex with men (MSM), few have ever tested. This study aimed to evaluate the feasibility and accuracy of HPV self-sampling among Chinese MSM, with the purpose of measuring the feasibility of self-sampling as an alternative in HPV testing scenarios.

METHODS

Eligible participants were those who were assigned male at birth, aged 18 or above, had sex with men in the past year and had never gotten HPV vaccine. Participants followed the instructions to self-sample and were also clinician-sampled from the same anatomical sites (oral fluid, penis and rectum) in both approaches. All specimens were processed using multiplex PCR assay. The reference standard of an individual with a true positive for HPV is determined via PCR test, regardless of sampling methods. Sensitivity and specificity were calculated for each approach independently and kappa test was used to assess the consistency between the two approaches.

RESULTS

Overall, 211 MSM were recruited at the local clinic from April to October 2020 in Zhuhai, China. The mean age was 31 years old. Only 3% of the participants sought help from healthcare providers during self-sampling. The prevalence of HPV was 49% (103 of 211). Clinician sampling detected 91 of 103 MSM infected with HPV, with a sensitivity of 88.3% (95% CI 80.2 to 93.6) and a specificity of 100.0% (95% CI 95.7 to 100.0). Self-sampling detected 81 of 103 MSM infected with HPV, with a sensitivity of 78.6% (95% CI 69.2 to 85.9) and a specificity of 100.0% (95% CI 95.7 to 100.0). The level of agreement was moderate between clinician sampling and self-sampling (k=0.67).

CONCLUSIONS

Self-sampled HPV testing demonstrated comparable accuracy and consistency to clinician sampling among MSM in China. It holds the potential to complement sexual health services especially among key populations.

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.

Social and Structural Barriers to Primary Care Access Among Women Living With HIV in Metro Vancouver, Canada: A Longitudinal Cohort Study

ABSTRACT

This study examines correlates of being unable to access primary care in the past 6 months among cisgender (cis) and trans women living with HIV (WLWH). Data were drawn from a longitudinal community-based cohort study of WLWH (ages 14+) in Metro Vancouver, Canada (2014-2017). Of 291 participants contributing 914 observations, 15.5% reported being unable to access primary care at baseline. In multivariable analysis, increased odds of being unable to access primary care was associated with (a) having im/migrated to Canada, and, in the past 6 months, (b) identifying as gender minority, (c) experiencing physical or sexual violence, (d) having suicidal ideation or attempts. Decreased odds were associated with recently accessing HIV-specific resources. Our findings suggest that primary health care for WLWH should address high levels of violence and mental health conditions as well as barriers to services for gender minority and im/migrant WLWH.

A randomized pilot trial to evaluate the benefit of the concomitant use of atorvastatin and Raltegravir on immunological markers in protease-inhibitor-treated subjects living with HIV

Objective

Optimization of antiretroviral therapy and anti-inflammatory treatments, such as statins, are among the strategies aimed at reducing metabolic disorders, inflammation and immune activation in people living with HIV (PLWH). We evaluated the potential benefit of combining both strategies.

Design

Forty-two PLWH aged ≥40 years receiving a protease inhibitor (PI)-based regimen were randomized (1:1) to switch from PI to Raltegravir (n = 20), or to remain on PI (n = 22). After 24 weeks, all patients received atorvastatin 20mg/day for 48 weeks.

Methods

We analyzed plasma inflammatory as well as T-cell maturation, activation, exhaustion and senescence markers at baseline, 24 and 72 weeks,

Results

Plasma inflammatory markers remained unchanged. Furthermore, no major changes on T-cell maturation subsets, immunoactivation, exhaustion or immunosenescence markers in both CD4 and CD8 T cell compartments were observed. Only a modest decrease in the frequency of CD38⁺ CD8 T cells and an increase in the frequency of CD28^-CD57⁺ in both CD4 and CD8 T-cell compartments were noticed in the Raltegravir-switched group.

Conclusions

The study combined antiretroviral switch to Raltegravir and Statin-based anti-inflammatory strategies to reduce inflammation and chronic immune activation in PLWH. Although this combination was safe and well tolerated, it had minimal impact on inflammatory and immunological markers.

Clinical Trials Registration

NCT02577042.

Assessing Gaps in Comprehensive HIV Care Across Settings of Care for Women Living with HIV in Canada

Background: Women living with HIV in Canada experience barriers to comprehensive HIV care. We sought to describe care gaps across a typology of care. Methods: We analyzed baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). A typology of care was characterized by primary HIV physician and care setting. Quality-of-care indicators included the following: Pap test, Pap test discussions, reproductive goal discussions, breast cancer screening, antiretroviral therapy (ART) use, adherence, HIV viral load, and viral load discussions. We defined comprehensive care with three indicators: Pap test, viral load, and either reproductive goal discussions over last 3 years or breast cancer screening, as indicated. Multivariable logistic regression analyses measured associations between care types and quality-of-care indicators. Results: Among women living with HIV accessing HIV care, 56.4% (657/1,164) experienced at least one gap in comprehensive care, most commonly reproductive goal discussions. Women accessed care from three types of care: (1) physicians (specialist and family physicians) in HIV clinics (71.6%); (2) specialists in non-HIV clinics (17.6%); and (3) family physicians in non-HIV clinics (10.8%), with 55.5%, 63.9%, and 50.8% gaps in comprehensive care, respectively. Type 3 care had double the odds of not being on ART: adjusted odds ratio (AOR 2.09, 95% confidence interval [CI] 1.16-3.75), while Type 2 care had higher odds of not having discussed the importance of Pap tests (AOR 1.48, 95% CI 1.00-2.21). Discussion: Women continue to experience gaps in care, across types of care, indicating the need to evaluate and strengthen women-centered models of care.

A study of outpatient healthcare use by ageing people with HIV

BACKGROUND

Antiretroviral treatment has turned HIV infection into a chronic condition with a near normal life expectancy and an ageing patient population. For a well-defined proportion of these patients, HIV-care could pass from specialty care to primary care, especially for prevention and treatment of additional chronic diseases. A better understanding of the complex health needs of this particular proportion is needed to determine the optimal way to integrate specialist and primary care.

OBJECTIVES

Our objective was to examine the health-seeking behaviour of ageing HIV patients. We investigated which physicians they consulted and the reasons for encounter. We also explored patients' participation in preventive healthcare activities.

METHODS

We conducted a retrospective descriptive cohort study among adults, 60 years of age or older living with HIV, who came for a routine consultation visit at the HIV clinic of the Institute of Tropical Medicine (ITM) over a period of 9 months. Those who met the inclusion criteria were offered a self-administered questionnaire. The responses were manually coded, exported into Excel and subsequently imported into SPSS for descriptive statistical analysis.

RESULTS

We analysed questionnaires from 74 patients, 11 women and 63 men. Since their last consultation visit at the ITM, 48 patients consulted their general practitioner (GP), 35 patients consulted a specialist and 7 went to the emergency department over a period of 6 months. Forty-nine patients (66%) had done a faecal occult blood test and 8 women (73% of female patients) had a screening mammography in the past 2 years, 8 women (73% of female patients) had a PAP smear in the past 3 years. Sixty-three participants (85%) declared that their vaccinations were up-to-date. Thirty-eight patients (51%) take antihypertensive medication, 35 patients (47%) cholesterol medication and 9 participants (12%) are on oral antihyperglycemic medication.

CONCLUSIONS

A large proportion of patients are seeking healthcare from their GP and specialists, other than the HIV specialist. They do so both for curative and preventive health needs. This calls for a more structured collaboration between the various care providers, whereby communication plays a pivotal role.

The organizational attributes of HIV care delivery models in Canada: A cross-sectional study

HIV treatment in Canada has rapidly progressed with the advent of new drug therapies and approaches to care. With this evolution, there is increasing interest in Canada in understanding the current delivery of HIV care, specifically where care is delivered, how, and by whom, to inform the design of care models required to meet the evolving needs of the population. We conducted a cross-sectional survey of Canadian care settings identified as delivering HIV care between June 2015 and January 2016. Given known potential differences in delivery approaches, we stratified settings as primary care or specialist settings, and described their structure, geographic location, populations served, health human resources, technological resources, and available clinical services. We received responses from 22 of 43 contacted care settings located in seven Canadian provinces (51.2% response rate). The total number of patients and HIV patients served by the participating settings was 38,060 and 17,678, respectively (mean number of HIV patients in primary care settings = 1,005, mean number of HIV patients in specialist care settings = 562). Settings were urban for 20 of the 22 (90.9%) clinics and 14 (63.6%) were entirely HIV focused. Primary care settings were more likely to offer preventative services (e.g., cervical smear, needle exchange, IUD insertion, chronic disease self-management program) than specialist settings. The study illustrates diversity in Canadian HIV care settings. All settings were team based, but primary care settings offered a broader range of preventative services and comprehensive access to mental health services, including addictions and peer support.

Patient activation among people living with HIV: a cross-sectional comparative analysis with people living with diabetes mellitus

Standardized self-management supports are an integral part of care delivery for many chronic conditions. We used the validated Patient Activation Measure (PAM®) to assess level of engagement for self-management from a sample of 165 people living with HIV (PLWH) and 163 people with diabetes. We conducted multivariable logistic regression to assess associations between demographics and PAM® scores. PLWH had high levels of activation that were no different from those of people with diabetes (mean score = 67.2, SD = 14.2 versus 65.0, SD = 14.9, p = 0.183). After adjusting for patient characteristics, only being on disability compared to being employed or a student was associated with being less activated (AOR = 0.276, 95%CI = 0.103-0.742). Our findings highlight the potential for the implementation of existing standardized chronic disease self-management programs to enhance the care delivery for PLWH, with people on disability as potential target populations.

HPV self-sampling: A promising approach to reduce cervical cancer screening disparities in Canada

Human papillomavirus (HPV) is the primary cause of cervical, anal, and other genital cancers, which are preventable through screening and early treatment. [...]

HIV-positive MSM's knowledge of HPV and anal cancer self-sampling: A scoping review

Human papillomavirus (hpv) infection is the cause of anal squamous cell cancer (ascc) in 80% of cases. Available research has also shown high prevalence of anal hpv infection among men who have sex with men (msm). However, hpv vaccination is low among msm in Canada. In light of this information, we conducted a scoping review with the aim of exploring (1) the knowledge of hpv and anal cancer among hiv-positive msm and (2) the acceptability of hpv and anal cancer self-sampling in this population. In conducting the review, we searched five electronic databases for peer-reviewed articles and abstracts published in English, between 2007 and 2017. A total of 803 articles were retrieved; after accounting for duplicates (n=40) and unmet criteria (n=754), a total of 794 articles were excluded. A final total of nine articles were used in this review. Results of this review show that hiv-positive msm have limited knowledge regarding the risks of anal cancer associated with hiv and hpv coinfection. Furthermore, there is limited research on hpv and anal cancer self-sampling in this population. However, the review of available studies suggested that hiv-positive msm were open to anal cancer self-sampling. It also identified potential barriers to self-sampling. In conclusion, we provide suggestions and future directions for policy-makers and educators to develop inclusive and accessible strategies to reach hiv-positive msm regarding anal cancer education and self-screening.

Knowledge of HPV/cervical cancer and acceptability of HPV self-sampling among women living with HIV: A scoping review

Cervical cancer rates are disproportionately high among women living with the human immunodeficiency virus (wlhiv). Cervical cancer is preventable through hpv screening, regular Pap tests, and early cancer detection. Evidence indicates that hpv and cervical cancer screening are suboptimal among wlhiv, who face a myriad of access barriers. Considering that screening is an effective first-line defense to cervical cancer, we conducted a scoping review with the aim of gaining a better understanding about: (1) the knowledge and perceptions of hpv and cervical cancer screening among wlhiv; and (2) the acceptability of self-sampling for hpv among wlhiv. We searched five electronic databases for peer-reviewed articles that were published in English within the last ten years, reported on studies with hiv-positive women who were aged 16 or older, and satisfied the topics of the review. A total of 621 articles were found. After accounting for duplicates and unmet criteria, 17 articles and 1 abstract, reporting on studies in the United States and Africa, were included in this review. The review highlighted that most wlhiv had inadequate knowledge of hpv transmission and cervical cancer prevention, which influenced their perceptions of risk and susceptibility. Screening barriers included misconceptions about Pap tests, fear of diagnosis of serious illness, perceived pain, embarrassment, bodily modesty, and limited access to female health care providers. This review also affirms that self-sampling is an acceptable and promising screening option for wlhiv. Implications for policy, research, and practice are discussed.

Cervical cancer screening uptake among HIV-positive women in Ontario, Canada: A population-based retrospective cohort study

Cervical cancer caused by oncogenic types of the human papillomavirus (HPV) is of concern among HIV-positive women due to impairment of immune responses required to control HPV infection. Our objectives were to describe patterns of cervical cancer screening using Pap cytology testing among HIV-positive women in Ontario, Canada from 2008 to 2013 and to identify factors associated with adequate screening. We conducted a retrospective, population-based cohort study among screen-eligible HIV-positive women using provincial administrative health data. We estimated annual proportions tested and reported these with 95% confidence intervals (CI). Next, using person-years as the unit of analysis, we identified factors associated with annual Pap testing using log-binomial regression. A total of 2271 women were followed over 10,697 person-years. In 2008, 34.0% (95%CI 31.1-37.0%) had a Pap test. By 2013, the proportion of HIV-positive women tested was 25.9% (95%CI 23.6-28.2%). Women who were most likely to undergo testing were younger, were immigrants from countries with generalized HIV epidemics, lived in the highest income neighbourhoods, had a female primary care physician, had two or more encounters per year with an infectious disease or internal medicine specialist, and had greater comorbidity. Nearly three in four HIV-positive women were under-screened despite all having universal insurance for medically-necessary services. Annual Pap testing decreased following the 2011-2013 release of new guidelines for a lengthened screen interval for average risk women and a billing disincentive. Clinic-based intervention such as physician alerts or reminders may be needed to improve screening coverage among HIV-positive women.

A cross-sectional population-based study of breast cancer screening among women with HIV in Ontario, Canada

BACKGROUND

As women with HIV live longer, the need for age-appropriate breast cancer screening will increase. We compared rates of screening mammography among women with and without HIV.

METHODS

We used administrative health databases to identify all women in Ontario, Canada, who were eligible for screening mammography (aged 50 to 74 yr and no history of breast cancer) as of Apr. 1, 2011. We used multivariable log-binomial regression to compare the 2-year period prevalence of screening mammography in 2011 to 2013 among women with and without HIV and to examine the correlates of screening among women with HIV.

RESULTS

We identified 1 447 015 screen-eligible women, among whom 623 (0.04%) were women with HIV. Women with HIV were less likely to undergo screening than women without HIV (50.1% v. 63.4%, p < 0.001). Following multivariable adjustment, HIV-positive status was associated with significantly lower odds of undergoing mammography (adjusted prevalence ratio [PR] 0.83, 95% confidence interval [CI] 0.77-0.89). Compared with women with HIV receiving regular care from both a family physician and an HIV specialist, women with HIV receiving neither kind of care (adjusted PR 0.64, 95% CI 0.50-0.83) or predominantly specialist care (adjusted PR 0.77; 95% CI 0.60 to 0.97) were less likely to undergo screening mammography.

INTERPRETATION

Women with HIV are less likely to undergo breast cancer screening mammography than women without HIV. Addressing this disparity requires optimizing care delivery to ensure adequate provision of comprehensive primary care to people with HIV.

Understanding Care Linkage and Engagement Across 15 Adolescent Clinics: Provider Perspectives and Implications for Newly HIV-Infected Youth

The National HIV/AIDS Strategy emphasizes rapid care linkage and engagement for HIV-infected individuals, though many adolescents are never tested, delay entering care, and frequently drop out. We conducted 183 staff interviews at 15 adolescent medicine clinics (baseline, n = 64; Year 1, n = 60; Year 2, = 59). We used a constant comparative thematic method to examine how providers approached and discussed care linkage/engagement. Qualitative analyses revealed differences in providers' conceptualizations of linkage and engagement. Providers saw linkage as mechanistic and health system driven. It was defined by number of clinic visits and involved relatively little youth agency. In contrast, providers defined engagement by youths' responsibility and participation in their own care. Linkage and engagement are related but distinct aspects of care that require different resources and levels of staff involvement. Integrating an understanding of these differences into future interventions will allow clinic staff to help youth improve long-term health outcomes.

Health profiles and associated service use among adults with HIV and intellectual and developmental disabilities

OBJECTIVE(S)

Owing to the commonly held notion that individuals with intellectual and developmental disabilities (IDD) have low risk of HIV acquisition, we compared the prevalence of HIV infection among people with and without IDD. We also examined health status and health service use among the HIV-infected group.

DESIGN

Population-based cohort study using linked administrative health and social services databases.

METHODS

We compared HIV prevalence between Ontario adults with IDD (n = 64 008) and a 20% random sample of Ontario adults without IDD. Among the HIV-infected group, we compared adults with and without IDD in terms of comorbid chronic physical conditions and mental health disorders, as well as use of overall health services, mental health services, and HIV-specific services.

RESULTS

HIV prevalence per 100 000 population did not differ for adults with IDD [163.38 (95% confidence interval: 132.27, 199.6)] and without IDD [172.45 (95 confidence interval: 167.48, 177.53)]. Among the HIV-infected group, those with IDD had more comorbid chronic physical conditions and mental health disorders. They also had greater use of overall health services and mental health services. Likelihood of use of HIV-specific services also differed for those with and without IDD.

DISCUSSION

A similar prevalence of HIV among adults with and without IDD accentuates a need for strategies for individuals with IDD to be included in HIV prevention efforts. High prevalence of chronic physical and mental health comorbidity and health service use among the HIV-infected group with IDD highlight a need for comprehensive and coordinated treatment plans to optimize outcomes for this complex patient group.

Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes

BACKGROUND

Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care.

METHODS

We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics.

RESULTS

Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68).

CONCLUSIONS

Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.

Human Immunodeficiency Virus (HIV) Quality Indicators Are Similar Across HIV Care Delivery Models

BACKGROUND

There are limited data on human immunodeficiency virus (HIV) quality indicators according to model of HIV care delivery. Comparing HIV quality indicators by HIV care model could help inform best practices because patients achieving higher levels of quality indicators may have a mortality benefit.

METHODS

Using the Partners HIV Cohort, we categorized 1565 patients into 3 HIV care models: infectious disease provider only (ID), generalist only (generalist), or infectious disease provider and generalist (ID plus generalist). We examined 12 HIV quality indicators used by 5 major medical and quality associations and grouped them into 4 domains: process, screening, immunization, and HIV management. We used generalized estimating equations to account for most common provider and multivariable analyses adjusted for prespecified covariates to compare composite rates of HIV quality indicator completion.

RESULTS

We found significant differences between HIV care models, with the ID plus generalists group achieving significantly higher quality measures than the ID group in HIV management (94.4% vs 91.7%, P = .03) and higher quality measures than generalists in immunization (87.8% vs 80.6%, P = .03) in multivariable adjusted analyses. All models achieved rates that equaled or surpassed previously reported quality indicator rates. The absolute differences between groups were small and ranged from 2% to 7%.

CONCLUSIONS

Our results suggest that multiple HIV care models are effective with respect to HIV quality metrics. Factors to consider when determining HIV care model include healthcare setting, feasibility, and physician and patient preference.

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.

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.