US studies underline importance of primary care physicians for people with HIV

People with HIV who have other medical conditions such as high blood pressure or high lipids appear to do better if they have a primary care physician as well as an HIV physician, according to a study of people receiving care through UCLA Center for Clinical AIDS Research and Education, researchers report in The Journal of Infectious Diseases.

A second study, looking at chronic medical conditions, or co-morbidities, in a large sample of people with HIV in the United States found that high blood pressure (hypertension), elevated lipids and endocrine disorders (including diabetes) were the most common co-morbid conditions, and that the proportion of people with HIV in care also receiving treatment for several co-morbid conditions rose significantly between 2003 and 2013.

As people with HIV grow older and HIV infection becomes increasingly well-controlled through antiretroviral treatment, a growing proportion of the care needed by people with HIV is for chronic medical conditions. Some are related to HIV infection or may be exacerbated by long-term inflammation due to HIV. Antiretroviral treatment may also increase the prevalence of some conditions, including high lipid levels, reduced kidney function, fractures and osteoporosis.

To find out which co-morbid conditions are more common in people with HIV, US researchers carried out a review of claims submitted to US health insurance companies, to Medicare and to Medicaid between 2003 and 2013 relating to all medical care apart from HIV diagnosis. The study identified claims relating to 36,298 people with HIV insured by commercial insurance companies, 26,246 by Medicaid (means-tested free insurance coverage for certain categories of US citizens) and 1854 by Medicare (health insurance for people aged 65 and over or qualifying disabled people).  

The most common co-morbidities were hypertension, hyperlipidaemia, endocrine disease (including diabetes), diabetes and renal impairment. The frequency of each co-morbidity was higher among Medicare claimants, who had a mean age of 71.5 years, compared to 41.6 years in the Medicaid group and 42.2 in the commercial insurance group. Claims relating to cardiovascular events and to renal impairment more than doubled between 2003 and 2013, as did claims for hyperlipidaemia.

When claims for HIV-positive people were compared with a demographically matched control group of HIV-negative people from the same insurance databases, commercially insured people with HIV were more likely to have undergone treatment for cardiovascular disease, deep vein thrombosis, hypertension, hepatitis C, renal impairment, fracture or osteoporosis, cancer, liver disease or alcoholism (p < 0.001). A similar pattern held true for people covered by Medicaid. Deep vein thrombosis, renal impairment and cancer were more frequent in HIV-positive people covered by Medicare compared to HIV-negative controls (p < 0.05).

The study authors say that part of the explanation for an increase in prevalence over time could lie in improved access to screening as a result of the 2010 Affordable Care Act, together with greater use of electronic medical records. Nevertheless, the high prevalence of co-morbidities observed in this study has also been reported in studies in the Netherlands and Switzerland, suggesting that the results are not simply a consequence of improvements in screening and recording.

Do people with HIV and other conditions do better if they have a primary care physician involved in their care?

The high prevalence of co-morbid conditions identified by the claims study emphasises the importance of screening for chronic health conditions and management according to guidelines. Many of the co-morbid conditions identified in the study of insurance claims can be managed by primary care physicians who may be more familiar with guidance on screening and management of these conditions.

The involvement of primary care physicians in the care of people with HIV varies depending on the way the health system is organised, and also where people with HIV seek care.

In the United Kingdom’s National Health Service, people with HIV receive antiretroviral treatment and some specialist care for co-morbid conditions through hospital-based HIV clinics. Patients at these clinics are encouraged to obtain treatment for hypertension, diabetes or elevated cholesterol from their primary care physician, but should receive regular monitoring from their HIV clinic.

In some countries, notably Germany and Australia, HIV care may be provided by primary care physicians who specialise in HIV treatment.

In the United States, numerous models of care exist. At UCLA Center for Clinical AIDS Research and Education in Los Angeles, primary care physicians are co-located within the HIV clinic to provide primary care. In other settings, people with HIV may receive all their medical care from an infectious disease specialist.

Researchers at UCLA Center for Clinical AIDS Research and Education compared rates of monitoring for co-morbid conditions and indicators of quality of care among 916 patients receiving care at the UCLA clinic.

The study compared outcomes between patients who received care only from an infectious disease physician (n = 168), those who received care from both an infectious disease physician and a primary care physician located at UCLA CARE clinic (n = 405), or from an infectious disease physician at CARE clinic and a primary care physician located elsewhere (n = 343).

The study population had a median age of 53 years, 93% were male, 72% were white and 13% African American.

The study identified 516 patients (56% of the cohort) who had been previously diagnosed with either hypertension, type 2 diabetes or hyperlipidaemia.

Diagnoses of all three conditions were significantly more common in people who received care from both an infectious disease physician and a primary care physician, either at the clinic or elsewhere (p < 0.001).

The study did not report whether a diagnosis of a co-morbid condition was more likely to occur in people with a primary care physician, so it is possible that the disparity could be explained by the need to see a primary care physician as a consequence of being diagnosed with one of the co-morbid conditions. However, the researchers found that individuals who visited a primary care physician in 2016 were more likely to have been screened for diabetes and elevated lipid levels compared to those who saw an infectious disease physician, although this difference was not statistically significant (p = 0.072 and p = 0.064 respectively).

There was a clear trend towards better control of cholesterol in those who had seen a primary care physician in 2016 (p = 0.065) and people who did not see a primary care physician were twice as likely to have LDL cholesterol above the recommended threshold (odds ratio 2.12, p = 0.070).

“Our research suggests that primary care services embedded within HIV clinics may improve monitoring and treatment of non-AIDS comorbidities,” the researchers conclude.