HIV: Experience Level of Family Physicians Matters

Diedtra Henderson

September 21, 2015

As antiretroviral therapy (ART) has transformed human immunodeficiency virus (HIV) infection into a manageable chronic condition, primary care physicians have been taking a larger role in caring for patients who are HIV-positive. Now, a new study published in the September/October issue of the Annals of Family Medicine suggests that family physicians who have 50 or more HIV-positive patients are more likely to adhere to ART protocols than their less experienced colleagues.

"[W]e found that family physician HIV experience was strongly associated with receipt of ART by HIV-positive patients, especially among those seeing only family physicians for their care; those seeing a family physician with the highest level of HIV experience were almost twice as likely to receive ART as counterparts seeing less experienced family physicians," Claire E. Kendall, MD, from the C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute; the Department of Family Medicine, University of Ottawa; and the Ottawa Hospital Research Institute, all of them in Ottawa, Ontario, Canada; and Institute for Clinical Evaluation, Toronto, Ontario, Canada; and colleagues write. "Given the need to shift HIV care to community-based models of care delivery, this study teases out the respective impacts of physician specialty and physician HIV experience by demonstrating that the most comprehensive care is delivered by family physicians with high HIV experience."

The authors tapped administrative databases to identify 11,427 people with HIV who had made outpatient physician visits in Ontario from April 1, 2009, to March 31, 2012; were linked to a usual family physician; and were still alive.

Some 52.8% were managed by primary care providers exclusively; 47.2% were seen by both family physicians and specialists.

"[P]atients of family physicians with the highest level of experience had the highest observed prevalence of receipt of ART among eligible patients, as well as the lowest observed prevalences of any emergency department visit and any hospital admission," Dr Kendall and coauthors write.

"Among patients cared for exclusively in primary care, receipt of ART was significantly lower among those receiving care from family physicians with 5 or fewer patients and 6 to 49 patients compared with those receiving care from family physicians with 50 or more patients."

Ninety-one percent of patients who saw family physicians with considerable HIV experience were male, and their mean age was 45 years. Eighty-four percent of such patients were born in Canada. Just 7.5% were immigrants from Africa or the Caribbean, whom the authors note "represent a growing proportion of new and prevalent HIV infections in Canada."

Among the limitations of the study, the authors only could determine whether patients eligible for public drug benefits received ART prescriptions; they could not tell whether they filled them or took the medicine.

"Sixteen percent of HIV patients in Ontario receive care exclusively from family physicians with lower HIV experience; our results suggest potential disparities in ART among these patients," the authors conclude. "Because we also found that this influence of family physician HIV experience is mitigated by having an HIV specialist within their model of care, in order to ensure adequate ART prescribing, care delivery models for people with HIV should include either an HIV specialist or a family physician with considerable HIV experience."

Financial support for the study was provided by the Ontario Ministry of Health and Long-term Care and the Institute for Clinical Evaluative Sciences. The authors have disclosed no relevant financial relationships.

Ann Fam Med. Published online September 14, 2015. Full text

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