{"id":10974,"date":"2024-05-28T08:54:01","date_gmt":"2024-05-28T12:54:01","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=10974"},"modified":"2024-05-28T11:38:36","modified_gmt":"2024-05-28T15:38:36","slug":"more-on-id-doctors-and-primary-care-for-people-with-hiv","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/more-on-id-doctors-and-primary-care-for-people-with-hiv\/2024\/05\/28\/","title":{"rendered":"More on ID Doctors and Primary Care for People with HIV"},"content":{"rendered":"
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People waiting to see their new primary care doctor.<\/p><\/div>\n

A recently published study<\/a> suggested that “non-ID doctors do better” when it comes to providing primary care to people with HIV.<\/p>\n

At least that was the attention-grabbing subject line of an email summary distributed by a local primary care doctor, Dr. Geoffrey Modest. He periodically sends around detailed descriptions of studies he finds interesting, then posts them on his blog.\u00a0<\/a>Sign up, it’s great value!<\/p>\n

But does this recent study really say that? And does it help answer the “who should do HIV primary care” debate? Let’s take a quick look at the study design and results.<\/p>\n

Under the auspices of the CDC’s Medical Monitoring Project, 6323 adults receiving HIV care from 2019-2021 were included. The investigators selected a random group to undergo a phone or face-to-face interview. Patients from 16 states and Puerto Rico participated.<\/p>\n

The clinical endpoints of interest as summarized in the abstract:<\/p>\n

… retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust.<\/p><\/blockquote>\n

Compared to the non-ID providers, the ID providers’ patients were less likely to be “retained in care” (83.1% vs 89.7%), and less likely to be screened for STIs (40.1% vs 49.5%), both comparisons statistically significant. Outcomes improved when ID doctors worked with a PA or NP.<\/p>\n

By contrast, no significant differences were observed with any of the other metrics. This included by far the most important marker of HIV outcomes in 2024, which is viral suppression.<\/p>\n

A study like this, of course, has limitations, most notably the non-randomized design, meaning those patients who receive primary care from ID doctors differed in many ways from those who went to non-ID specialists. While the investigators adjusted for demographic and other differences, residual confounding is always a possibility. I can certainly attest to the fact that at least here in Boston, many HIV patients who have ID doctors as their primary providers do so because they have no previous regular provider of any<\/em> sort prior to their diagnosis.<\/p>\n

And they can’t get a primary care doctor, an issue I’ll come to in a bit.<\/p>\n

In addition, the “retention in care” metric is kind of weird, specifically:<\/p>\n

… retention in care, defined as \u22652 elements of HIV care (including documented or self-reported outpatient encounters with an HIV care provider, HIV-related laboratory test results, ART prescriptions), at least 90 days apart.<\/em><\/p><\/blockquote>\n

For the record, many of my most stable patients long ago graduated to annual visits and blood test monitoring — admittedly in violation of guidelines that advocate for twice-yearly visits. Before you tsk-tsk at this “infrequent” care,\u00a0how strong is the evidence that a person with HIV with virologic suppression for decades must have their labs checked twice yearly? I suspect these rock-solid stable patients wouldn’t qualify as being “retained in care” by the study’s definition, but they’re definitely not lost to follow-up.<\/p>\n

In other words, my conclusion from this paper is that based on the metrics chosen<\/em>, the quality of care for most people with HIV is pretty darn similar, regardless of their specialty, and that those who worked as a team — with an NP or PA — did a touch better with STI screening.<\/p>\n

The results don’t surprise me much — HIV care in stable patients is, well, usually very stable. Hooray! It does not require a specialist’s expertise and raises the question once again why, in this phenomenally successful current ART era, we need ID doctors to do HIV primary care.<\/p>\n

Indeed, my last take on this issue<\/a> argued that it was time for us to move to a model more like the one we have for oncology or rheumatology patients, with ID specialists still playing a major role when HIV and its complications are active, and patients returning to primary care once stable. A periodic visit with an HIV expert can support primary care clinicians for issues related to ART switches and new treatment options, managing side effects and drug interactions, or clinical applications of advances in the field.<\/p>\n

The clinical endpoints of the study also don’t get to the core reason why many of us ID doctors would be thrilled if our patients also had a generalist primary care doctor — especially our older patients with multiple medical comorbidities. Instead of these HIV-related endpoints, what if the study chose non-HIV-related<\/em> measures of the quality of care, including control of hypertension, diabetes, cardiovascular risk, guidelines-recommended cancer screening, and musculoskeletal pain?<\/p>\n

In other words, these and other aging-related endpoints — none ID-related — would be far more relevant to the issue of primary care quality done by an ID specialist than the outcomes the investigators reported.<\/p>\n

But before we ask our patients to switch their primary care to generalists, we once again must point out that this will be easier said than done. Primary care providers don’t grow on trees — or, if they do, these trees are pretty rare flora around these parts. A very important person recently asked me, on behalf of another big-time academic who just moved to Boston, for the names of good primary care doctors for him, his wife, and his two adult children.<\/p>\n

Ha.<\/p>\n

If she’d asked me for a thoracic surgeon, an ophthalmologist, an oncologist who specializes in breast cancer (to cite three recent successful examples of referrals), no problem. But a primary care doctor? The shortage is so bad that the giant healthcare system I work in, the largest in New England, stopped accepting new patients late last year<\/a>. The wait even for established patients to get into see their primary care doctors for a non-urgent problem can be 6 months or longer.<\/p>\n

You think these beleaguered PCPs could add people with HIV to their panel?<\/p>\n

So we’ll continue to do primary care for now because there’s a desperate shortage of generalists. In some patients, we’ll be managing the only active medical problem they have, either because HIV is not yet stable, or they are otherwise healthy and their problem list is very short, with just one item:\u00a0 HIV.<\/p>\n

In the older patients with stable HIV and multiple medical problems, we’ll do our best, with generous use of our subspecialty colleagues as needed — because some primary care is vastly better than none.<\/p>\n","protected":false},"excerpt":{"rendered":"

A recently published study suggested that “non-ID doctors do better” when it comes to providing primary care to people with HIV. At least that was the attention-grabbing subject line of an email summary distributed by a local primary care doctor, Dr. Geoffrey Modest. He periodically sends around detailed descriptions of studies he finds interesting, then […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,8,9],"tags":[],"class_list":["post-10974","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-patient-care","category-policy"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/10974","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=10974"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/10974\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=10974"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=10974"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=10974"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}