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Provider Experience, Life Stressors Drive HIV Adherence

A novel twist on the concept of “meeting people where they are” may hold the key to retaining new HIV patients, and may even bring the elusive goal of ending the AIDS epidemic a bit closer.

While that concept commonly refers to community outreach and engagement, understanding patient experiences and expectations as well as their individual life stressors in the actual clinic setting may improve overall outcomes, according to new research published online January 5 in AIDS and Behavior.

In fact, accounting for both expectations and life stressors may help physicians predict which patients will be lost to follow-up (LTFU) during the first year of HIV care.

Dr Emmanuel Guajardo

“Medical science is not necessarily [at the forefront] of where we want to focus our efforts right now,” Emmanuel Guajardo, MD, lead study author and instructor of infectious diseases at Baylor College of Medicine in Houston, Texas, told Medscape Medical News.

Rather, “we need to focus on retention in care and adherence to medications. Doubling down on these efforts could really go a long way toward ending the HIV epidemic,” he said.

First Time’s a Charm

The investigators studied 450 patients attending an HIV clinic in Houston who were asked to complete a post-visit survey detailing their experience with the HIV healthcare provider and their personal life stressors in the preceding 6 months. Study participants were predominantly non-Hispanic Black (54.2%) or Hispanic (30.7%) and were mostly men who have sex with men ― populations that are similar to the patients seen at Guajardo’s clinic. Patients were given the option of completing the survey while awaiting discharge, doing so within 2 weeks of their visit to the clinic, or (as a last resort) by phone.

Overall scores were based on a composite of validated scales:

  • Patient experience scores were defined dichotomously (best experience, most positive experience vs not the best experience).

  • Life stressor events (death, relationship, economic) were assigned weighted scores based on life-change impact (eg, death of a spouse received a score of 100, while moved/changed living location was assigned a score of 25).

“We found that patients who reported better initial experiences with their provider at the first visit were less likely to be lost to follow-up at 6 and 12 months,” explained Guajardo. He added that having fewer life stressors at the first visit was also protective.

At 6 months, mean overall patient experience scores were 8.60 for those LTFU, vs and 8.98 for those not LTFU (P = .011). At 12 months, mean scores were 8.43 in the LTFU group and 8.98 for those not LTFU (P = .001).

For the dichotomized scoring, patients who reported the best experience with the provider were significantly less likely to be LTFU at 6 months (adjusted odds ratio [aOR], 0.866; P = .038) and 12 months (aOR, 1.263; P = .029) compared with those not reporting the best experience.

Mean life change scores appeared to portend patient drop-off; patients who reported more stressful life events were likelier to be LTFU at 6 months (mean life change score, 129, vs 100 for those retained in care) and at 12 months (126 vs 101).

Corresponding multivariate logistic regression models that controlled for age, baseline CD4 cell count <200, and diagnosis ≤3 months showed that patients with higher life stressor burden were significantly more likely to be LTFU at both 6 months (aOR, 1.232; P = .037) and 12 months (aOR, 1.263; P = .029).

Approach Matters

“The [study] really hits the nail on the head in terms of identifying a couple of these very salient issues that affect people’s care, especially concerning HIV,” Philip A. Chan, MD, infectious disease specialist and associate professor of medicine at Brown University in Providence, Rhode Island, told Medscape Medical News. Chan was not involved in the study.

Dr Philip Chan

“It highlights things that we see on the ground that can interfere with HIV care or PrEP care, just healthcare in general, certainly one’s relationship with the physician or provider, and also real life stressors,” he said.

Relationship building is especially important for historically underserved populations, a point that’s hardly lost on either Chan or Guajardo, who both pointed to higher levels of mistrust among certain patient populations due to their being mistreated by the healthcare system. The answer? Let the patients lead the initial discussions and allow them to feel comfortable and participate in their care in ways that are most beneficial to them.

“There’s so much miscommunication, misunderstanding, and stigma related to HIV out in the community. So, it’s important to really open the floor for whatever they want to talk about first, before I push any agenda on a new patient,” Guajardo said. Thereafter, he relies on open-ended questions (eg, “Tell me about your sexual partners,” or “What sort of sexual practices do you engage in?”).

“At the end of the day, you just need someone dedicated who can be respectful and listening and caring and dedicate time to patients to help keep them in care, to listen, and to navigate our incredibly, incredibly complex healthcare system,” Chan added.

Guajardo and Chan report no relevant financial relationships.

AIDS Behav. Published online January 5, 2022. Abstract

Liz Scherer is an independent journalist specializing in infectious and emerging diseases, cannabinoid therapeutics, neurology, oncology, and women’s health.

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