A Population-Based Study Evaluating Family Physicians’ HIV Experience and Care of People Living With HIV in Ontario

We would like to thank Kendall, et al. for their study furthering the evidence behind collaborative HIV care, particularly models that include family medicine clinicians.[1] In the United States, where major system-level changes are occurring in the healthcare landscape, studies such as this one are important in informing transitions to new HIV care models.

Many in the world of HIV care have long-stated that HIV programs were one of the original "medical homes",[2] highlighting the team-based, often multi-disciplinary nature of successful HIV care. The work of Kendall et al. here, along with efforts from other investigators, reaffirms the importance and complexity of primary care delivery to people living with HIV. In this study, among subjects who were only followed by primary care providers, the authors confirm that more HIV experience among providers was associated with a greater likelihood of antiretroviral therapy (ART) receipt. Additionally, patients who were cared for exclusively by primary care providers, i.e., did not receive any co-management, were prescribed ART less frequently than those who received any type of clinical co-management (regardless of whether HIV care was delivered mostly by the consulting specialist or family physician, and also regardless of the collaborating family physician's HIV experience). Since the study was based on administrative data including billing information, access to individual test results (i.e. CD4 and HIV viral load) was not available, thus limiting any conclusions about other clinically-relevant outcomes. Furthermore, if guidelines in Ontario during the study years of 2009-2012 advocated particular CD4 thresholds for ART initiation similar to those recommended in the U.S (CD4 < 350-500 cells/mm3; optional for patients with higher CD4 counts), we would expect prescribing patterns might have been affected by patient CD4 level. This study cannot inform us of the relative importance of clinical stage versus provider training/experience/care model on ART prescription. Finally, the category of mid-level HIV volume (6-49 patients/provider) remains a very heterogeneous group bearing further exploration. Although authors identified this range of patient volume based on a previous systematic review and meta-analysis, some HIV expertise-certifying professional and regulatory agencies in the U.S. currently use a panel size closer to 20-25 patients to delineate significant HIV management experience.[3-4]

The most striking finding might be that specialist involvement is attended by remarkably and consistently high levels (86-90%) of ART receipt, regardless of whether care is specialist-dominant or family physician-dominant, and regardless of number of HIV patients in the collaborating family physician practice. This raises some possibilities that are not addressed in this study but would be helpful to understand. Are there policies or customs that dictate which patients are referred for specialty evaluation? For example, if referral is customary at a CD4 threshold or with HIV-related clinical manifestations, it might explain the high ART prescription rate among co-managed patients. Conversely, are there factors that influence which patients do not get referred to a specialist or receive care with an HIV-experienced provider? For example, if this group includes large numbers of patients who refuse to or prefer not to see a specialist/HIV expert, might they also be less inclined to take ART? Recent U.S. studies have consistently suggested HIV-specific treatment outcomes (particularly viral suppression on ART) are equivalent among patients followed by community-located primary care providers compared to hospital-based specialists, especially when HIV expertise is incorporated effectively.[5-6] Accordingly, both the possibility and utility of primary care-based HIV management have been demonstrated and reaffirmed. It might be that certain subtleties in patient preferences and clinical status, and/or the degree of integration and coordination between HIV and primary care and other available services (i.e. case management, mental health, etc.), influence how well-suited certain care models are for different patients and providers. Additionally, Kendall's study reinforces the importance of general healthcare and screening for HIV-infected individuals. The population of people aging with HIV has grown tremendously in areas where ART has been delivered successfully, and providers caring for HIV-infected persons--specialists and generalists alike--must remain vigilant about indicated clinical monitoring. This includes screening for conditions ranging from chronic co-morbidities such as diabetes to various (and often age-associated) cancers where clear guidelines exist.

The Clinician Consultation Center (CCC) has provided free HIV management consultation to all U.S.-affiliated providers for more than 20 years (nccc.ucsf.edu). During this time the CCC has observed a remarkable shift and growth in the diversity of callers who use its services, reflecting both a geographic diffusion of the HIV epidemic as well as the changing nature of HIV care, involving a more diverse group of primary care-trained clinicians. This change in HIV primary care delivery has occurred for a multitude of reasons including wait time for specialty appointments and prohibitive travel distance for specialty centers as well as a contracting HIV expert workforce. Current U.S. HIV treatment guidelines recommend the use of simpler, better-tolerated, and more robust regimens. Now more than ever, primary care providers can and should provide high-quality HIV care which will often mean incorporating an HIV expert--whether it's a local colleague or through a remote consultation service such as the CCC. For busy primary care providers, it is vital they have access to a consultant who can provide the latest evidence-informed decision support and tips for achieving best clinical practices in a manner that remains patient-centered and responsive to the provider's needs and capabilities. Although the right level of HIV expertise may remain undefined, family medicine and other primary care providers are delivering high-quality HIV care and can continue to do so for the years to come.

Carolyn Chu, MD, MSc(a), Kate Cummings, MPH(a), Ron H. Goldschmidt, MD(a), Peter A. Selwyn, MD, MPH(b)

Affiliations: (a) UCSF/SFGH Clinician Consultation Center and the UCSF Department of Family and Community Medicine; (b) Montefiore Medical Center/Albert Einstein College of Medicine Department of Family and Social Medicine

References:
1. Kendall CE, Manuel DG, Younger J, Hogg W, Glazier RH, Taljaard M. A Population-Based Study Evaluating Family Physicians' HIV Experience and Care of People Living with HIV in Ontario. Ann Fam Med September/October 2015; 13: 436-445.
2. Saag MS. Ryan White: an Unintentional Home Builder. AIDS Reader 2009; 19: 166-168.
3. American Academy of HIV Medicine: www.aahivm.org/aahivs (accessed 10/7/2015)
4. New York State Department of Health AIDS Institute: https://www.health.ny.gov/diseases/aids/providers/standards/primarycaremedicaid/section4.htm (accessed 10/7/2015)
5. Schranz AJ, Brady KA, Momplaisir F, Metlay JP, Stephsn A, Yehia BR. Comparison of HIV outcomes for patients linked at hospital versus community-based clinics. AIDS Patient Care STDS. 2015 Mar; 29(3): 117-25.

6. Chu C, Umanski G, Blank A, Grossberg R, Selwyn PA. HIV-infected patients and treatment outcomes: an equivalence study of community-located, primary care-based HIV treatment versus hospital-based specialty care in the Bronx, New York. AIDS Care 2010; 22: 1522-1529

Competing interests: None declared