The State of Primary Care in HIV

September 18, 2012

Although survivors of HIV infection urgently need care from primary care providers, the best evidence shows that primary care cannot fill that need adequately at present, and may be less able to do so in the future.

The transition of HIV/AIDS from an acute, nearly always fatal disease to a chronic condition has also sparked a transition in care. Today, most HIV-infected individuals receive their care from primary care physicians, not from specialists. Indeed, a 2011 report from the Institute of Medicine’s Committee on HIV Screening and Access to Care noted the “strained” resources available to treat patients with HIV, and concluded that the only way to meet that need is with increased availability and training of primary care physicians (PCPs).

Just how well these physicians are meeting that need is the focus of a recent survey from HealthHIV, one of the largest non-profit organizations in the US focused on HIV. The Second Annual HealthHIV State of HIV Primary Care report provides a unique look at the integration of HIV into primary care, and how the landscape is changing year to year. It surveyed 1,806 physicians, nurse practitioners, physician assistants, pharmacists, and others regarding treatment approaches, services provided, reimbursement issues, comorbidities, and other issues pertinent to primary or specialty care.

A key finding is that demand for services is increasing among all physicians, even those who don’t routinely treat HIV. Yet there are substantial gaps in the confidence of primary care providers to provide those services.

While HIV specialists feel “highly confident” in their ability to treat the disease, HIV primary care providers (defined as those who spend at least 1% of their practice time treating HIV) consider themselves just “confident” and said their level of HIV education needs improvement. Other primary care providers (those who do not treat HIV patients) said they lack any confidence in their ability to treat these patients and have a low level of HIV education.

Specifically, PCPs who treat HIV said they were significantly less confident than credentialed HIV specialists in:

•    Prescribing anti-retroviral medications to a patient with a multidrug- resistant virus
•    Managing adverse effects of anti-retroviral drugs
•    Assessing when to begin therapy with a treatment-nave patient
•    Providing long-term HIV care

Primary care providers said the major barriers to providing quality HIV care are  a lack of clinical and support staff time to take on new roles and procedures, patient transportation issues, lack of referral partners for services they don’t offer, and lack of reimbursement.

Another major challenge is fragmentation across the health care system, said Brian Hujdich, executive director of HealthHIV. “The fractured landscape is becoming more and more apparent,” he said. “We expect the next survey to show even more fractures as we move into the next phase of implementation of healthcare reform.”

The survey also highlighted the rapidly shifting landscape of HIV care, as increasing numbers of HIV-positive people seek treatment even as the primary care and HIV specialty workforces shrink. The full implementation of the Affordable Care Act, will further strain the system, Hujdich said, by making health insurance more accessible to millions of people, including an estimated 850,000 people living with HIV.

Other key findings:

•    Primary care physicians who do not provide any HIV care said they do not routinely provide HIV testing, while even HIV primary care physicians said they provide such testing “inconsistently.” Barriers include patients who don’t want to be tested, low or no reimbursement, lack of time, and the perception that HIV is not a pressing issue in their community.
•    HIV PCPs are significantly less confident than credentialed HIV specialists in treating and monitoring hepatitis C-infected patients. This is troubling given that a substantial percentage of HIV patients are co-infected with hepatitis C.
•    HIV clinicians spend 36% of their time mostly on HIV and 26% mostly on co-occurring conditions. Thirty-eight percent spend equal amounts of time on both. They are also seeing an increase in the number of HIV-infected individuals with co-occurring conditions, particularly other sexually transmitted infections, cardiovascular disease, renal disease, and mental health issues.

Hujdich stressed one other trend identified in the report. Contrary to the commonly held belief that PCPs, particularly those in community health centers, don’t care about HIV-infected patients, “we see that PCPs involved in HIV are interested, they do care, and community health centers know have to address HIV because these patients are coming in the door.” There is also a sensitivity that primary care providers won’t be as valued or as crucial as specialists, he said. However,  “it’s the opposite; they are more valued.”

HealthHIV has already begun fielding the 2013 survey, which will include additional interviews with consumers, policy makers, and others in order to “analyze the full landscape” of HIV treatment in this country, Hujdich said.