Improving the Two Ends of the HIV Care Cascade With Provider-Patient Communication

Benjamin Young, MD, PhD


November 25, 2014

Around the world, access to HIV treatments is increasing, resulting in dramatic reductions in AIDS-related disease burden and death rates. The HIV care cascade provides a widely accepted framework for evaluating how populations of people are diagnosed and enter into and remain engaged in care and treatment.[1] Two publications in the current issue of the Journal of the International Association of Providers of AIDS Care (JIAPAC) address how provider-patient communication may critically affect outcomes at two ends of the cascade: improving testing coverage and health considerations after viral suppression.

There is much work to be done to optimize the care cascade, as only a minority of individuals in HIV-infected communities successfully achieves viral suppression. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently proposed ambitious cascade targets, called 90-90-90: By the year 2020, 90% of all people living with HIV will know their status; 90% of all people diagnosed will receive antiretroviral treatment; and 90% of those on treatment will have durable viral suppression.[2] A global survey of 1400 HIV care providers found widespread support for expanded antiretroviral therapy, yet many of those surveyed felt that there were substantial barriers to implementation.[3] In the fight to break down barriers to improving the HIV care cascade, increasing the number of people who know their HIV status is the first critical step.

While HIV testing as part of routine medical care has been recommended in the United States since 2006, on the basis of current data it is estimated that nearly 20% of HIV-infected individuals don't know their status. Yet, achieving near-universal HIV testing is possible, as evidenced by high levels of testing among pregnant women. Important barriers to testing exist, such as stigma or provider acceptance and education. Recognizing that HIV testing is most likely to occur not in HIV clinics but rather in primary care settings, investigators from the Baylor College of Medicine conducted a Web-based survey of 137 primary care physicians in publically funded health centers in the Houston, Texas area.[4] Their analysis found that 41% of respondents were unaware of updated 2013 HIV testing recommendations for testing individuals aged 15-65 years; a large number of respondents did not know that HIV testing should be offered to adolescents (46%) and to adults (24%) in primary care settings. Many individuals would probably accept HIV testing if offered by their healthcare provider, so improving provider knowledge of governmental or medical society recommendations should improving testing coverage. The authors pointed out that lack of knowledge of recommendations alone might not be the only barrier to improving clinical behavior, so additional research is needed to assess barriers to HIV testing.

For those individuals who successfully navigate the care cascade, UNAIDS targets high levels of durable viral suppression. While observational cohort studies demonstrate near-normal life expectancy for people living with HIV,[5] noncommunicable diseases such as cardiovascular (CVD) and liver disease are playing increasing roles in overall morbidity and mortality.[6] At this end of the HIV care cascade, provider-patient communication is also essential. Even though monitoring CVD risks in HIV patients is recommended, compliance with monitoring recommendations appears to be poor.[7] In a second publication in JIAPAC,[8] Sherer and colleagues explored this issue further. By conducting a global cross-sectional survey of provider-patient communication in more than 2000 adult patients, they found that only a minority (19%) reported ever having discussed CVD with their provider, roughly two thirds had never discussed CVD risk factors, and almost half of smokers never discussed smoking with their HIV provider. The authors call for urgent action. Interventions are known to significantly reduce CVD risk, yet without provider-patient communication on this issue, these interventions may go unattended.

Taken together, these two studies remind us that optimal health requires attention to provider-patient communication across the entire HIV care cascade. While care cascade metrics begin with testing and end with viral suppression, healthy aging with HIV requires attention to additional aspects of health and healthcare communication. Increasing awareness of normative guidance among care providers is a challenging though essential requirement. To achieve improved HIV testing coverage and prevention of noncommunicable diseases, knowledge of care recommendations must reach not only the HIV specialist but also busy healthcare providers with diverse professional backgrounds who care for at-risk individuals.


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