A novel twist on the concept of ‘meeting people where they are’ may hold the key to retaining new HIV patients, and even bringing the elusive goal of ending the AIDS epidemic a bit closer. While the concept commonly refers to community outreach and engagement, understanding patient experiences and expectations and personal life stressors in the actual clinic setting may improve overall outcomes, according to new research.
In fact, accounting for both expectations and life stressors may help physicians predict which patients will be lost to follow-up (LTFU) in the first year of HIV care.
“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.
Study findings were published published online January 5 in AIDS and Behavior.
First Time’s a Charm
Dr Emmanuel Guajardo
450 patients attending an HIV clinic in Houston were asked to complete a post-visit survey detailing their experience with the HIV clinician, as well as personal life stressors in the preceding 6 months. Study participants were predominantly non-Hispanic Black (54.2%) or Hispanic (30.7%) and mostly men who have sex with men (MSM), populations that mimic the patients seen at Guajardo’s clinic. Patients were given the option of survey completion while awaiting discharge, within 2 weeks at the clinic, or (as a last resort), by phone.
Overall scores were based on a composite of validated scales: 1) patient experience scores were defined dichotomously (best experience, most positive experience vs not the best experience), and 2) 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 (LTFU) at 6 and 12 months,” explained Guajardo. “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); corresponding mean scores at 12 months were 8.43 and 8.98 respectively (P = .001).
For the dichotomized scoring, patients reporting the best experience with the healthcare professional were significantly less likely to be LTFU at 6 months (adjusted odd ratio 0.866, P = .038) and 12 months (aOR 1.263, P = .029) vs those not reporting the best experience.
Mean life change scores appeared to portend patient drop-off; patients reporting 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 (1.26 vs 101).
Corresponding multivariate logistic regression models controlling for age, baseline CD4 cell count <200, and diagnosis ≤3 months showed that patients with higher life stressor burdens 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.
“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, you know, real-life stressors,” said Chan, who was not involved with the study.
Dr Philip Chan
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 because of their mistreatment by the healthcare system. The answer? Let the patient lead the initial discussion, 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 such as ‘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.
This study was partly supported by use of the facilities and resources of the Houston VA Center for Innovations in Quality, Effectiveness and Safety and Harris Health System. Support for the study was also provided by the National Institute of Mental Health and The University of Texas MD Anderson Foundation Chair at Baylor College of Medicine. Guajardo and Chan have disclosed 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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