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

Enhancing the delivery of comprehensive care for people living with HIV in Canada: insights from citizen panels and a national stakeholder dialogue

BACKGROUND

People living with human immunodeficiency virus (HIV) are living longer with health-related disability associated with ageing, including complex conditions. However, health systems in Canada have not adapted to meet these comprehensive care needs.

METHODS

We convened three citizen panels and a national stakeholder dialogue. The panels were informed by a plain-language citizen brief that outlined data and evidence about the challenge/problem, elements of an approach for addressing it and implementation considerations. The national dialogue was informed by a more detailed version of the same brief that included a thematic analysis of the findings from the panels.

RESULTS

The 31 citizen panel participants emphasized the need for more prevention, testing and social supports, increased public education to address stigma and access to more timely data to inform system changes. The 21 system leaders emphasized the need to enhance person-centred care and for implementing learning and improvement across provinces, territories and Indigenous communities. Citizens and system leaders highlighted that policy actions need to acknowledge that HIV remains unique among conditions faced by Canadians.

CONCLUSIONS

Action will require a national learning collaborative to support spread and scale of successful prevention, care and support initiatives. Such a collaborative should be grounded in a rapid-learning and improvement approach that is anchored on the needs, perspectives and aspirations of people living with HIV; driven by timely data and evidence; supported by appropriate decision supports and aligned governance, financial and delivery arrangements; and enabled with a culture of and competencies for rapid learning and improvement.

Organisation and integrated healthcare approaches for people living with HIV, multimorbidity, or both: a systematic review

BACKGROUND

Universal recommendation for antiretroviral drugs and their effectiveness has put forward the challenge of assuring a chronic and continued care approach to PLHIV (People Living with HIV), pressured by aging and multimorbidity. Integrated approaches are emerging which are more responsive to that reality. Studying those approaches, and their relation to the what of delivery arrangements and the how of implementation processes, may support future strategies to attain more effective organizational responses.

METHODS

We reviewed empirical studies on either HIV, multimorbidity, or both. The studies were published between 2011 and 2020, describing integrated approaches, their design, implementation, and evaluation strategy. Quantitative, qualitative, or mixed methods were included. Electronic databases reviewed cover PubMed, SCOPUS, and Web of Science. A narrative analysis was conducted on each study, and data extraction was accomplished according to the Effective Practice and Organisation of Care taxonomy of health systems interventions.

RESULTS

A total of 30 studies, reporting 22 different interventions, were analysed. In general, interventions were grounded and guided by models and frameworks, and focused on specific subpopulations, or priority groups at increased risk of poorer outcomes. Interventions mixed multiple integrated components. Delivery arrangements targeted more frequently clinical integration (n = 13), and care in proximity, community or online-telephone based (n = 15). Interventions reported investments in the role of users, through self-management support (n = 16), and in coordination, through multidisciplinary teams (n = 9) and continuity of care (n = 8). Implementation strategies targeted educational and training activities (n = 12), and less often, mechanisms of iterative improvement (n = 3). At the level of organizational design and governance, interventions mobilised users and communities through representation, at boards and committees, and through consultancy, along different phases of the design process (n = 11).

CONCLUSION

The data advance important lessons and considerations to take steps forward from disease-focused care to integrated care at two critical levels: design and implementation. Multidisciplinary work, continuity of care, and meaningful engagement of users seem crucial to attain care that is comprehensive and more proximal, within or cross organizations, or sectors. Promising practices are advanced at the level of design, implementation, and evaluation, that set integration as a continued process of improvement and value professionals and users' knowledge as assets along those phases.

TRIAL REGISTRATION

PROSPERO number CRD42020194117.

Life With HIV in a Canadian Suburban Community: A Qualitative Inquiry of Health Care and Social Services Access

HIV has been examined in urban and rural contexts, but the suburban gradient has not been sufficiently described, despite the fact that many Canadians live in suburbia. Using qualitative description, we investigated how people living with HIV in a suburban community in Ontario, Canada, accessed health care and social services. Posters at the regional AIDS Service Organization and snowball sampling were used to recruit and interview 13 adult participants with various experiences and perspectives. A content analysis identified three meta-themes in the interviews: (a) transportation cost and time: barriers to access, (b) isolation, and (c) defective primary care: unmet and deflected needs. The findings have implications for the (a) development of community-based groups, (b) the role of transportation in health care and social services utilization, (c) community-based, interprofessional health and social care services, and (d) aging with HIV.

Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service

Background. Electronic consultation (eConsultation) is a potential strategy to improve access to specialist expertise and facilitate collaborative care models. The Champlain BASE eConsult service allows for asynchronous communication between primary care providers (PCP) and specialists on a secure, web-based system. HIV experts accessible include HIV physician specialists, HIV pharmacists, and social workers with expertise in HIV. Objective. This study aims to describe the use, value, and utility of this eConsultation service in the care of people living with HIV and to characterize the common question types and clinical topics asked by PCPs. Methods. We analyzed the data from eConsults sent to the HIV specialty group in Ontario’s Champlain Local Health Integration Network between February 2015 and December 2017. Usage data and close-out survey responses were analyzed using descriptive statistics, eConsults were classified using a predefined list of validated taxonomy, and a thematic analysis was performed on the consultation logs to identify common clinical themes. Results. Among the 46 eConsults, the most common question type related to drug treatment (58.7%, n = 27) and management (19.6%, n = 9). The main clinical themes involved the care of significant complexities in people living with HIV, such as comorbidities and drug interactions, and suggestions of coordinated patient care. As well, eConsult was used for advice regarding pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection. PCPs highly valued the eConsult service (average rating 4.8/5). Conclusion. Overall, this study demonstrates that eConsult provides an efficient and valuable service to PCPs caring for patients living with or at risk for HIV by improving access to HIV specialists and facilitating the delivery of team-based comprehensive care.

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.

Measuring the impact of an HIV rotation on trainees' knowledge and confidence level: The importance of inviting recent graduates

BACKGROUND

The new Canadian Residency Accreditation Consortium (CanRAC) standards recommend surveying recently graduated trainees to target improvements in training programs. The goal of this study was to estimate the impact of a rotation in an HIV clinic on trainees' related knowledge, confidence, and practice profile at the Université de Montréal.

METHODS

An electronic survey was sent to practising physicians who completed the rotation between 2006 and 2016. Participants were asked to rate their agreement and level of confidence toward HIV- and HCV-related topics using 5-point Likert scales (0 to 4). Descriptive statistics and mean comparisons were calculated.

RESULTS

Among invited participants, 27 of 45 (60%) completed the questionnaire. The majority of respondents were infectious diseases physicians (48%) or family physicians (37%) and had an outpatient caseload of <10 HIV patients/year (80%). For 37% of the respondents, the rotation had a large or very large impact on their career path. They considered that the rotation had increased their knowledge on the overall management of HIV (mean 3.2/4 [95% CI 2.9 to 3.4]), but less on pre-exposure prophylaxis (PrEP) (mean 1.5/4 [95% CI 1.1 to 2.0]) or HCV care (mean 1.9/4 [95% CI 1.4 to 2.3]). Participants felt less confident with genotyping interpretation (mean 2.6/4 [95% CI 2.2 to 2.9]) and PrEP (mean 2.4/4 [95% CI 2.0 to 2.8]).

CONCLUSIONS

These results suggest that a rotation in an HIV clinic improves knowledge related to HIV care. Feedback from past graduates helped us identify gaps in knowledge or level of confidence in PrEP and HCV care, which will feed curriculum improvement.

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.

Postpartum mental health service utilization in women with Human Immunodeficiency Virus (HIV): a population-based study

Women with HIV have higher rates of psychiatric disorders than HIV-negative women, yet little is known about their postpartum mental health and associated service use. The purpose of this study was to characterize HIV-positive women's use of ambulatory and acute mental health services in the first year postpartum, relative to HIV-negative women. Using health administrative data, we identified 861,365 women who had a live birth delivery from April 1, 2002 to March 31, 2012 in Ontario, Canada, of whom 530 were identified to be HIV-positive. We described their use of mental health services, including outpatient mental health visits, psychiatric emergency department (ED) visits and hospitalizations using adjusted odds ratios (aORs) and 95% confidence intervals (CIs). HIV-positive women were more likely to access outpatient mental health services (31.5% vs. 21.0%, aOR, 1.26; 95% CI, 1.03-1.55), but more likely to remain engaged in psychiatrist services only (15.6% vs. 6.5%, aOR, 2.35; 95% CI, 1.41-3.72). They were also more likely to require a psychiatric ED visit or hospitalization (3.3% vs. 1.1%, aOR, 2.74; 95% CI, 1.72-4.12). Our findings highlight the importance of considering postpartum mental health as part of comprehensive reproductive health care for women with HIV.

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.

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.

Emergency department use by people with HIV in Ontario: a population-based cohort study

BACKGROUND

Emergency department use may reflect poor access to primary care. Our objective was to compare rates and causes of emergency department use between adults living with and without HIV.

METHODS

We conducted a population-based study involving Ontario residents living with and without HIV between Apr. 1, 2011, and Mar. 31, 2012. We frequency matched adults with HIV to 4 HIV-negative people by age, sex and census division, and used random-effects negative binomial regression to compare rates of emergency department use. We classified visits as low urgency or high urgency, and also examined visits for ambulatory care sensitive conditions. Hospital admission following an emergency department visit was a secondary outcome.

RESULTS

We identified 14 534 people with HIV and 58 136 HIV-negative individuals. Rates of emergency department use were higher among people with HIV (67.3 v. 31.2 visits per 100 person-years; adjusted rate ratio 1.58, 95% confidence interval [CI] 1.51-1.65). Similar results were observed for low-urgency visits. With the exception of hypertension, visit rates for ambulatory care sensitive conditions were higher among people with HIV. People with HIV were also more likely than HIV-negative individuals to be admitted to hospital following an emergency department visit (adjusted odds ratio 1.55, 95% CI 1.43-1.69).

INTERPRETATION

Compared with HIV-negative individuals, people with HIV had high rates of emergency department use, including potentially avoidable visits. These findings strongly support the need for comprehensive care for people with HIV.

Developing a performance framework for measuring comprehensive, community-based primary healthcare for people with HIV

OBJECTIVES

People with human immunodeficiency virus (HIV) are living longer lives and like many other patients, need a health system better adapted for the management of complex chronic conditions. A key element of system transformation is measuring and reporting on system performance indicators relevant to the different stakeholders. Our objective was to produce a performance measurement framework for assessing the quality of comprehensive community-based primary healthcare for people with HIV.

METHODS

Semi-structured interviews were performed with HIV providers, advocates, and policy-makers to obtain input on a draft performance framework, constructed using existing HIV-specific indicators, as well as the use of performance data in improving care for people with HIV.

RESULTS

Stakeholders were overwhelmingly supportive of the framework's comprehensiveness. Many noted the absence of indicators addressing social determinants of health and had mixed opinions on the importance of indicators addressing access to after-hours care and the frequency of routine screening for behavioural risk factors. The draft framework was modified to reflect stakeholder input, triangulated against expert opinion and recently released HIV care guidelines, and finalized at 79 indicators. The resources and infrastructure to collect and use performance data will have to be improved for performance measurement to contribute to improving care for people with HIV.

CONCLUSIONS

This framework presents a comprehensive though not exhaustive tool to support performance measurement and improvement in the care for people with HIV. However, advances in data collection and use across the system will be needed to support performance measurement driving quality improvement.