Patients' and GPs' worries about confidentiality, drug-drug interactions, and poor communication between primary and secondary care continue to be barriers to the integration of general practices into the care and management of HIV-positive individuals, the 14th Annual Conference of the British HIV Association (BHIVA) heard last week.
Of concern is that this study – based on two surveys of more than 220 patients and 174 GPs in Brighton – comes from the UK city that is a shining example of best practice when it comes to HIV education for GPs and extra funding. Since 2005, Brighton’s HIV clinic has been running an interactive two-day HIV-ED course for interested GPs and their practice nurses. In addition, the local Primary Care Trust funds locally enhanced services for HIV. Both are a rarity in the UK.
Historical barriers to integration
Standards of care documents from MedFASH and BHIVA both recommend that some aspects of HIV management should take place within primary care. However, for a variety of reasons, historically there has been reluctance from both GPs and patients, noted Michelle Kennedy of Brighton and Sussex Medical School, presenting.
In order to better understand barriers to the integration of GPs into HIV-positive patient care, investigators at Brighton’s HIV clinic developed two questionnaire-based studies – one for GPs and one for patients – utilising a series of statements exploring various concerns.
The questionnaire was offered to all patients attending Brighton’s HIV outpatient clinic between March and May 2007, and posted to all GPs in the city of Brighton & Hove during the same period.
Of 475 HIV-positive individuals invited to take part, 222 filled in a questionnaire (resulting in a 47% response rate). The majority were white gay men, consistent with Brighton’s demographics.
Plurality of concerns
The investigators were surprised to find that 207 (93%) had, in fact, registered with a GP and of those, 174 (84%) had disclosed their HIV status to their GP, somewhat higher than in pre-HAART UK studies.
Of 174 GPs in Brighton & Hove, 124 (71%) completed a questionnaire. Of those 109 (88%) had treated five or more HIV-positive patients and 76 (61%) had attended the HIV-ED course.
More than a third of patients felt that their GP lacked sufficient HIV knowledge (38%) and experience (36%) and a sizeable proportion of GPs agreed that they did not have enough experience (44%), although fewer had concerns over their knowledge of HIV (27%).
The investigators were surprised that 50% of patients were not worried about the confidentiality of GP practices, even though 94% of GPs felt that they could maintain the confidentiality of the HIV-positive patients in their practice. However, they noted, “this still leaves half the patients in our study who, for some reason or another, had still not received this message and still see confidentiality as an important barrier.”
Despite a recent study from London finding HIV-associated discrimination amongst GPs, a negative attitude from the GP (in terms of judging a patient’s lifestyle) was neither perceived (18%) nor expressed (4%) by a majority of patients or GPs in both studies.
GPs worried about cost, drugs, interactions and poor communication
However, there were an additional three areas of concern for GPs (these questions were not asked of patients).
Despite locally enhanced services being available in Brighton & Hove (which pay GPs extra money for looking after HIV-positive patients), 59% of GPs cited cost as an important barrier.
In addition, 79% of GPs felt unsure about current antiretrovirals, including interactions and side-effects. “We felt this was a little worrying,” said the investigators, “as a third of GPs also felt that communication with secondary care was currently inadequate.”
In fact, another study presented to the conference as a poster, from London’s Royal Free Hospital, highlights the issue of poor communication and drug interactions when HIV-positive patients on protease inhibitor-based therapy are prescribed statins via their GP.
A retrospective case notes review enhanced by patient interview in the first half of 2007 found that, of the 95 patients receiving a statin during this period, 26 (16 on atorvastatin; 10 on pravastatin; 14 on PI-based ART) had their lipid-lowering prescriptions transfered to a GP, primarily via a letter. However, only 5% of letters highlighted that co-administration of simvastatin and PIs is contraindicated.
Following this transfer of care, only 14 of the 26 patients (52%) continued on the same statin; a quarter discontinued the statin due to non-attendance at primary care; one patient refused to pay NHS prescription charges and returned to the HIV clinic; and in 19%, the GP initiated simvastatin, including in two patients who were taking PI-based ART.
The investigators recommend that communication with GPs must specifically state relevant contraindications and stress that close follow-up is essential. Alternatively, they suggest that ongoing statin prescribing should remain a responsibility of HIV practitioners.
Disclosure and GP training reap rewards
When the Brighton investigators compared the patients who had not disclosed their HIV status to their GPs with patients who had, they found that every barrier listed (GP knowledge, GP experience, confidentiality concerns, GP attitude, and patient preference) was perceived by the majority of patients who had not disclosed their HIV status.
Unsurprisingly, all of these barriers were significantly less likely to be perceived if the patient had disclosed their HIV status compared to patients who had not.
The investigators also compared GPs who had attended HIV-ED training courses with those who had not and found that trained GPs were significantly more comfortable with their HIV knowledge and experience and felt up to date with current ART (around 70% of those trained versus half of those not trained).
Similar results were found when GPs who had treated ten or more HIV-positive patients were compared to GPs who had treated fewer than ten HIV-positive patients.
Better communication, training and experience are key
“From the patient’s perspective,” noted Michelle Kennedy, “it seems that contact with primary care practice has lessened many of the historically-conceived barriers, and this may be due to changed policies within practices.”
From the GP perspective, she stressed that “the key is training and experience.” Although the investigators identified drug knowledge and cost as important barriers, they think that this may be due to GPs’ erroneous concerns about prescribing anti-HIV treatment through primary care in the future, which is not being recommended by either MedFASH or BHIVA.
She concluded with several recommendations.
- HIV-positive patients should be encouraged to register and disclose to GPs.
- HIV specialists should reassure patients and dispel myths that are preventing them from accessing primary healthcare services.
- More prominent and visible confidentiality agreements should be displayed in GP's practices.
- Improvement in communication between primary and secondary care is needed, and this may be through improved correspondence from specialists to GPs.
- Rather than expect all GPs to have HIV-positive patients, “perhaps a better approach might be to encourage interested GPs to have regular training”.
“Ultimately,” Ms Kennedy said, “if GPs are willing to become HIV-aware and both specialists and patients are willing to train them, then a high level of primary care is achievable for all patients with HIV.”
The July 2006 edition of AIDS Treatment Update (Issue 158) includes a detailed analysis of the issues facing patients and GPs in integrating HIV-positive individuals into primary care.
Kennedy M et al. Understanding the barriers to GP involvement in the care of patients with HIV. Fourteenth BHIVA Conference, Belfast: abstract O6, 2008.
Benn PD et al. Is best practice to devolve statin prescribing to primary care in patients on HAART? Fourteenth BHIVA Conference, Belfast: abstract P126, 2008.