Caring for people with AIDS and HIV infection in hospital-based primary care practice

The nature of multidisciplinary HIV care in the ambulatory setting: a synthesis of the literature

The purpose of this article is to provide a critical appraisal and synthesis of the literature relating to the provision of multidisciplinary HIV care in the ambulatory setting. As more people are living with HIV infection, and living longer, the demand for chronic care is great. Knowing what optimal care and treatment for people living with HIV/AIDS is and how to provide that care is an ongoing challenge. The literature suggests that the provision of care for HIV-infected individuals varies across and within HIV/AIDS clinics. This variability in care practices may influence the health and well-being of patients, and negatively impact on access to such care by people with HIV/AIDS. The goal of reviewing the literature on HIV-ambulatory clinics was to provide a description of a typical clinic, its staffing components, the care practices carried out at such a clinic (and by whom), and some barriers to providing optimal care. The ultimate goal of this review is to establish what is currently known about the provision of these services so that this information may build on existing knowledge and thereby standards of care for HIV-ambulatory clinics can be developed that could be implemented on a wide-scale basis.

HIV/AIDS challenges the normative model of healthcare delivery in Canada

With advances in therapeutics, effective therapy for human immunodeficiency virus (HIV) has shifted the focus of HIV care from an acute illness to a chronic disease requiring the services of several disciplines in a primary care setting. This article describes a collaborative model in the delivery of HIV care for HIV-infected individuals who remain fragile, both physically and psychosocially.

Challenges in providing comprehensive and coordinated care to HIV/AIDS patients: a Canadian perspective

This article focuses our attention on the means by which healthcare is provided to HIV-infected patients who require comprehensive and coordinated care to address the variety of changing and challenging needs presented by the acquired immunodeficiency syndrome (AIDS). Improved clinical management of HIV infection over the past decade, with antiretroviral agents, protease inhibitors and prophylactic therapies against opportunistic infections has transformed HIV infection from an acute to a chronic illness. Many individuals with AIDS are now living longer with more chronic conditions. Concomitant with the transformation of HIV infection from an acute to a chronic illness comes the challenge to provide effective, humane and economical care to patients with chronic conditions that continue to reside in the community, within a healthcare delivery system that has evolved to treat patients with acute diseases.

Delays in protease inhibitor use in clinical practice

OBJECTIVE

To determine the clinical factors associated with delayed protease inhibitor initiation.

DESIGN

Chart review and telephone survey.

SETTING

General medicine practice at an academic medical center in Boston, Mass.

PATIENTS

One hundred ninety patients living with HIV and a viral load of more than 10,000 copies/ml.

MEASUREMENTS AND MAIN RESULTS

The main outcome measurement was time to first protease inhibitor prescription after first elevated HIV viral load (>10,000 copies/ml). In this cohort, 190 patients had an elevated viral load (median age 39; 87% male; 12% history of injection drug use; 63% AIDS; 53% with depression; 17% history of pneumocystis pneumonia; 54% CD4 <200). In Cox proportional hazards modeling, significant univariate correlates for delayed protease inhibitor initiation were higher CD4 cell count (hazard ratio [HR] 2. 38 for CD4 200-500 compared with <200, 95% confidence interval [CI] 1.59, 3.57; and HR 8.33 for CD4> 500; 95% CI 2.63, 25.0), higher viral load (HR 0.43 for each 10-fold increase; 95% CI 0.31, 0.59), injection drug use (HR 2.08; 95% CI 1.05, 4.17), AIDS (HR 0.24; 95% CI 0.15, 0.36), and history of pneumocystis pneumonia (HR 0.32; 95% CI 0.21, 0.49). In multivariate models adjusted for secular trends in protease inhibitor use, factors significantly associated with delay of protease inhibitor initiation (p <.05) were higher CD4 cell count (for CD4 200-500, HR 2.63; 95% CI 1.61, 4.17; for CD4> 500, HR 11.11; 95% CI 3.57, 33.33), higher viral load (HR 0.66 for each 10-fold increase; 95% CI 0.45, 0.98), history of pneumocystis pneumonia (HR 0.57; 95% CI 0.37, 0.90), history of depression (HR 1. 49; 95% CI 1.03, 2.13), and history of injection drug use (HR 2.70; 95% CI 1.35, 5.56).

CONCLUSIONS

HIV-infected patients with higher CD4 cell counts or a history of depression or history of injection drug use have significant and lengthy delays of protease inhibitor therapy. Although some delays may be clinically appropriate, enhancement of provider and patient education might prove beneficial. Further research should examine reasons for delays in protease inhibitor initiation and their appropriateness.

Structure of a primary care support system to coordinate comprehensive care for children and families infected/affected by human immunodeficiency virus in a managed care environment

BACKGROUND

Children with HIV infection require coordinated primary and tertiary care.

OBJECTIVES

To describe the structure of the Wisconsin HIV Primary Care Support Network, a decentralized program for care of children and families infected or affected by HIV infection.

METHODS

Review of data concerning all children with HIV infection included in the Network's database.

RESULTS

In this Network centralized HIV specialists work with primary care practitioners throughout Wisconsin to assure that children with HIV infection have access to care of uniform quality no matter where they live. Network staff care for children with HIV infection both directly and through the education and support of primary care providers. Care requirements are outlined in a state-published protocol supplied to practitioners. Audit of care is possible because of a centralized data collection system, and ongoing feedback and education occur via the activities of nursing care coordinators and both hospital- and community-based social workers.

CONCLUSIONS

This system of care may serve as a model for care delivery to children with HIV infection in low prevalence areas and may be applicable to the care of children with other chronic diseases being cared for in a managed care environment.

Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival

BACKGROUND

Previous studies have found that patients with the acquired immunodeficiency syndrome (AIDS) who are admitted to hospitals that admit many such patients have lower mortality rates than patients in hospitals with less experience with AIDS. We examined the relation between physicians' experience with AIDS and the survival of their patients with AIDS.

METHODS

We studied 403 adult male patients enrolled in a staff-model health maintenance organization in whom first AIDS-defining illnesses were diagnosed from 1984 through mid-1994; we determined that these illnesses met the 1987 case definition of the Centers for Disease Control. We defined three levels of experience for the patients' 125 primary care physicians according to their experience with AIDS during residency training and the cumulative number of patients with AIDS they had cared for in their practices.

RESULTS

The median survival of the patients of physicians with the least experience in the management of AIDS was 14 months, as compared with 26 months for the patients of physicians with the most experience (P<0.001). Controlling for the severity of illness and the year of diagnosis, we found that the patients cared for by physicians with the most experience had a 31 percent lower risk of death than the patients cared for by physicians with the least experience (P<0.02). Among 244 patients with an AIDS-defining illness diagnosed from 1989 through 1994, after adjustment for the CD4+ cell count and the severity of illness, the risk of death was 44 percent lower for patients of the most experienced physicians than for patients of the least experienced (P<0.02).

CONCLUSIONS

The experience of primary care physicians in the management of AIDS is significantly associated with survival among their patients.

Guidelines for management of HIV infection with computer-based patient's record

Computers are steadily being incorporated in clinical practice. We conducted a nonrandomised, controlled, prospective trial of electronic messages designed to enhance adherence to clinical practice guidelines. We studied 126 physicians and nurse practitioners who used electronic medical records when caring for 349 patients with HIV infection in a primary care practice. We analysed the response times of clinicians to the situations that triggered alerts and reminders, the number of ambulatory visits, and hospitalisation. The median response times to 303 alerts in the intervention group and 388 alerts in the control group were 11 and 52 days (p < 0.0001), respectively. The median response time to 432 reminders in the intervention group was 114 days and that for 360 reminders in the control group was over 500 days (p < 0.0001). There was no effect on visits to the primary care practice. There was, however, a significant increase in the rate of visits outside the primary care practice (p = 0.02), which is explained by the increased frequency of visits to ophthalmologists. There were no differences in admission rates (p = 0.47), in admissions for pneumocystosis (p = 0.09), in visits to the emergency ward (p = 0.24), or in survival (p = 0.19). We conclude that the electronic medical record was effective in helping clinicians adhere to practice guidelines.

Primary care and HIV disease

Nearly one million Americans are infected with the human immunodeficiency virus (HIV). With the advent of increasingly effective therapy, including intervention early in the course of infection, there will be a growing need for physicians technically and attitudinally prepared to provide primary care for HIV-infected individuals. For any disease, however, determination of which physicians provide the bulk of care depends on several factors, including the prevalence and chronicity of the disease, the complexity, rate of change, and toxicity of therapy, and the socioeconomic characteristics of patients with the disease. General internists will clearly constitute a large part of the pool of practitioners caring for HIV-infected patients, especially in the earlier stages of infection. It seems reasonable to expect every general internist to be competent in four aspects of HIV care: counseling about transmission and prevention; the proper administration and interpretation of diagnostic tests; monitoring and care of patients in early stages of infection; and recognition of complications of advanced infection for proper management or referral. Academically based generalists will have a major role in research, teaching, and patient care in the AIDS epidemic. The organization and delivery of primary and specialty care for HIV-infected people in future years will continue to evolve with changes in therapy and in the demography of the epidemic.