Barriers to Obtaining Waivers to Prescribe Buprenorphine for Opioid Addiction Treatment Among HIV Physicians

Background Illicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine. Objective To examine barriers to obtaining waivers to prescribe buprenorphine. Design Cross-sectional survey study. Participants 375 physicians attending HIV educational conferences in six cities in 2006. Approach Anonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression. Results 25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [95% CI] = 1.08–3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32–0.97) were significantly associated with having a buprenorphine waiver. Conclusions Among HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.     

Healthcare services for Japanese elderly long-staying in Thailand from the perspective of the patient and healthcare providers: A survey study

Long-stay refers to a long visit abroad by retired middle-aged and older people. This study describes the attitudes/opinions of elderly Japanese long-staying subjects and healthcare providers in Thailand. Two cross-sectional questionnaire surveys were conducted in Chiang Mai Province, Thailand. Questionnaires were sent to a sample recruited from a self-help group of Japanese elders in Thailand (n = 68) and to Thai healthcare providers (n = 101). About half of the Japanese subjects routinely used a Thai medical service, although only 15% had been admitted to the hospital. Half of the Japanese subjects thought the quality of Thai medical services was high. Many elderly Japanese subjects were unable to speak either English or Thai, leading to communication difficulties. About 80% of healthcare professionals found no difference between caring for elderly Japanese subjects and people from Thailand. Most healthcare providers agreed that Japanese language training should be available to medical staff as translators were not always available. Healthcare providers agreed with the Thai government policy promoting long-stays. The most recognized obstacle in caring for Japanese long-stay elderly was the language barrier. More research on Japanese elders staying abroad is needed to promote effective communication between Japanese elderly and other ethnic healthcare professionals.     

Inequality and unwillingness to care for people living with HIV/AIDS: a survey of medical professionals in Southeast China

This study was aimed at assessing physicians' and physician assistants' knowledge and attitudes toward HIV/AIDS and identifying determinants of willingness to care for infected individuals in Southeast China. From May to June 2004, 454 physicians and physician assistants from 5 different medical facility levels in Fujian Province, China, undertook a survey on knowledge, attitude, behavior, and practice (KABP). Only 40.4% (95% confidence intervals: 35.9, 44.9) were willing to provide healthcare services for people living with HIV/AIDS (PLWHAs). Knowledge (p < 0.001) and attitude scores (p = 0.01) as well as the proportion of those willing to provide care (p < 0.001) significantly differed by facility level. Multivariate analysis identified supportive attitudes toward PLWHAs (p < 0.001), self-confidence in providing care (p < 0.001), and facility level as significant predictors of willingness to care for infected individuals. Village medical stations showed the most unfavorable outcomes. Enhanced education as well as specific programs promoting supportive attitudes and willingness to care is therefore required, especially among those working at lower facility levels in remote areas.     

Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients

BACKGROUND: Current HIV treatment guidelines recommend delaying antiretroviral therapy for nonadherent patients, which some fear may disproportionately affect certain populations and contribute to disparities in care. OBJECTIVES: To examine the relationship of physician's attitude toward prescribing protease inhibitors (PIs) to nonadherent patients with disparities in PI use and with health outcomes. DESIGN: Prospective cohort study. PATIENTS AND SETTING: A national probability sample of HIV-infected adults in the United States and their health care providers was surveyed between January 1996 and January 1998. We analyzed data on 1717 patients eligible for PI treatment and the 367 providers who cared for them. MEASUREMENTS: Providers' attitude toward prescribing PIs to nonadherent patients, time until patients' first receipt of PIs, mortality, and physical health status. MAIN RESULTS: Eighty-nine percent of providers agreed that patient adherence is important in their decision to prescribe PIs (Selective) while 11% disagreed (Nonselective). Patients who had a Selective provider received PIs later than those with a Nonselective provider (P =.05). Adjusting for patient demographics and health characteristics and provider demographics, HIV knowledge, and experience, Latinos, women, and poor patients received PIs later if their provider had a Selective attitude but as soon as others if their provider had a Nonselective attitude. African-American patients received PIs later than whites, irrespective of their providers' prescribing attitude. Patients with Selective providers had similar odds of mortality than those with Nonselective providers (odds ratio, 1.1; 95% confidence interval, 0.6 to 2.0), but had slightly worse adjusted physical health status at follow-up (49.1 vs 50.4, respectively; P =.04), after controlling for baseline physical health status and other patient and provider covariates. CONCLUSIONS: Most providers consider patient adherence an important factor in their decision to prescribe PIs. This attitude appears to account for the relatively later use of PI treatment among Latinos, women, and the poor. Given the rising HIV infection rates among minorities, women, and the poor, further investigation of this treatment strategy and its impact on HIV resistance and outcomes is warranted.     

Access to antiretroviral therapy during excess black-water flooding in central Thailand

Excess black-water flooding in central Thailand resulted in closure of several healthcare facilities in the Fall of 2011. Persons living with human immunodeficiency virus (HIV) infection were presumably at risk for interruption of antiretroviral therapy (ART), with consequent treatment failure. We conducted a retrospective cohort study of ART use among patients in care at a Thai HIV clinic that closed due to excess flood water. Among 217 patients on ART who had clinic appointments within the one-month interval before the floods through the one-month interval after the clinic re-opened, seven (3%) reported non-sustained ART access. Non-sustained ART access was independently associated with prior low self-reported ART adherence (P<0.001) and less than six-months duration on the ART regimen (P=0.03). Advanced ART receipt or procurement at other flood-free healthcare facilities were strategies associated with ART access. During a flood disaster, identification and close monitoring of at-risk patients, patient–staff communication, flood preparedness plans, “HIV care access for all” policies, and collaboration among patients, healthcare providers and the government are relevant issues within preparedness plans to optimize ART access.     

Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy

BACKGROUND: Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care. OBJECTIVE: To examine the relationship between choice of appropriate antiretroviral therapy (ART) to physician specialty and HIV/AIDS experience. DESIGN: Self-administered physician survey. PARTICIPANTS: Random sample of 2,478 internal medicine (IM) and infectious disease (ID) physicians. MEASUREMENTS: Choice of guideline-recommended ART. RESULTS: Two patients with HIV disease, differing only by CD4+ count and HIV RNA load, were presented. Respondents were asked whether ART was indicated, and if so, what ART regimen they would choose. Respondents' ART choices were categorized as "recommended" or not by Department of Health and Human Services guidelines. Respondents' HIV/AIDS experience was categorized as moderate to high (MOD/HI) or none to low (NO/LO). For Case 1, 72.9% of responding physicians chose recommended ART. Recommended ART was more likely (P <.01) to be chosen by ID physicians (88.2%) than by IM physicians (57.1%). Physicians with MOD/HI experience were also more likely (P <.01) to choose recommended ART than those with NO/LO experience. Finally, choice of ART was examined using logistic regression: specialty and HIV experience were found to be independent predictors of choosing recommended ART (for ID physicians, odds ratio [OR], 4.66; 95% confidence interval [95% CI], 3.15 to 6.90; and for MOD/HI experience, OR, 2.05; 95% CI, 1.33 to 3.16). Results for Case 2 were similar. When the analysis was repeated excluding physicians who indicated they would refer the HIV "patient," specialty and HIV experience were not significant predictors of choosing recommended ART. CONCLUSIONS: Guideline-recommended ART appears to be less likely to be chosen by generalists and physicians with less HIV/AIDS experience, although many of these physicians report they would refer these patients in clinical practice. These results lend support to current recommendations for routine expert consultant input in the management of those with HIV/AIDS.     

HIV Test Avoidance Among People Who Inject Drugs in Thailand

Case identification is a key component of HIV prevention efforts; yet rates of HIV testing remain low in some settings. We explored factors associated with HIV test avoidance among people who inject drugs (IDU) in Thailand. Between July and October 2011, 350 Thai IDU participated in the study. In bivariate analyses, male gender, high intensity drug use, syringe sharing, increased police presence, and being refused healthcare services were positively associated with HIV test avoidance, while ever receiving a hepatitis C test was negatively associated. Our findings highlight the need for interventions to reduce stigma in this setting.     

北京市三甲医院医务人员对感染HIV的医务人员的态度

目的调查分析北京市三甲医院医务人员,对于感染艾滋病病毒(HIV)的医务人员的态度。方法采用方便抽样的方法,对北京市三甲医院的医务人员进行自填式问卷调查,并做描述性分析。结果共调查医务人员392名,69.6%的人从未接受过HIV抗体检测,56.4%的人同意应该对医务人员强制进行HIV抗体检测,68.4%的人同意感染HIV的医务人员不能进行侵入性操作,40.8%的人同意感染HIV的医务人员在进行侵入性操作前,应该向病人说明自己的病情。以上四部分的态度与HIV暴露防护知识的相关系数没有统计学意义。结论大部分医务人员从未接受过HIV抗体检测,是否在医务人员中进行HIV抗体检测、对感染HIV的医务人员的从业规范做出相关规定,还需要进一步的研究论证。     

Drug Use, Increasing Incarceration Rates, and Prison-Associated HIV Risks in Thailand

Background: Incarceration is a known risk for HIV infection in Thai drug users. Through the 1990s, incarceration rates for drug-related offenses rose sharply, whereas HIV prevention and drug treatment in prisons remained limited. Methods: We assessed HIV and incarceration risks for injection drug users (IDU) and non-IDU in a large treatment center cohort in northern Thailand to investigate HIV and prison risks in this period. We used Thai Bureau of Corrections data to assess incarceration and prevention funds in prisons, 1992–2000. Results: Among 1,865 drug user in the treatment cohort, 503 (27.0%) had ever been jailed. Men (OR 3.3, 95% CI 2.1, 5.2), IDU (OR 6.3, 95% CI 5.1, 7.9), and men who have sex with men (MSM) (OR 3.4, 95% CI 1.8, 6.3) were more likely to have been jailed. Among male IDU who had ever been jailed (N = 272), 15.8% had used drugs in prison. In a multivariate model, incarceration and ever IDU remained independently associated with HIV infection; IDU, MSM behaviors, and harmful traditional practices remained independently associated with having been jailed. From 1992 to 2000, overall alleged narcotics offenses increased from 117,000 to 276,000/year. The number of persons incarcerated for narcotics offenses increased fivefold from 1992 to 1999, from 12,860 to 67,440. For FY 2000, narcotics treatment accounted for 0.06% of the Thai corrections budget, whereas HIV programs in prisons were 0.017%. Conclusions: Incarceration rates for narcotics offenses have increased sharply in Thailand, whereas prevention has lagged. Having been jailed is an important independent risk for HIV infection among Thai male drug users, especially IDU and MSM. HIV prevention and drug treatment are urgently needed in Thai prisons.     

Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians

PURPOSE: State legislatures have increased the prescribing capabilities of nurse practitioners and physician assistants and broadened the scope of their practice roles. To determine the impact of these changes, we compared outpatient antibiotic prescribing by practicing physicians, nonphysician clinicians, and resident physicians. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), we conducted a cross-sectional study of patients >/=18 years of age receiving care in 3 outpatient settings: office practices, hospital practices, and emergency departments, 1995-2000. We measured the proportion of all visits and visits for respiratory diagnoses where antibiotics are rarely indicated in which an antibiotic was prescribed by practitioner type. RESULTS: For all patient visits, nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians for visits in office practices (26.3% vs 16.2%), emergency departments (23.8% vs 18.2%), and hospital clinics (25.2% vs 14.6%). Similarly, for the subset of visits for respiratory conditions where antibiotics are rarely indicated, nonphysician clinicians prescribed antibiotics more often than practicing physicians in office practices (odds ratio [OR] 1.86, 95% confidence intervals [CI]: 1.05 to 3.29), and in hospital practices (OR 1.55, 95% CI: 1.12 to 2.15). In hospital practices, resident physicians had lower prescribing rates than practicing physicians for all visits as well as visits for respiratory conditions where antibiotics are rarely indicated (OR 0.56, 95% CI: 0.36 to 0.86). CONCLUSION: Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. These differences suggest that general educational campaigns to reduce antibiotic prescribing have not reached all providers.     

Specialty training and specialization among physicians who treat HIV/AIDS in the United States

OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with HIV-specific knowledge, referral patterns, and HIV-related education activities. DESIGN: Cross-sectional survey. SETTING: The United States. PARTICIPANTS: Physicians caring for patients in the HIV Costs and Service Utilization Study, a study of a probability sample of HIV-infected individuals in the United States. MEASUREMENTS AND MAIN RESULTS: Measures included physicians' reports of specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities. Approximately 72% (379) of the eligible physicians completed a survey. Of these, 152 (40%) had infectious disease (ID) training, and 213 (56%) were generalists; 4% of ID-trained physicians and 37% of generalist physicians did not consider themselves HIV experts. The median current caseloads were 150 and 200 patients for ID experts and generalist experts, respectively. In contrast, the median caseload for non-expert generalists was 5. Mean scores on the knowledge scale were similar for ID and generalist experts (9.0 items correct out of 11 vs 8.5; P=not significant), but lower for generalist non-experts (6.5 items correct; P <.01). Experts had attended more local and national HIV meetings than non-experts (9.3 vs 2.7; P <.01, and 2.3 vs.40; P <.01, respectively) in the past year. Fewer ID experts ever referred than generalist experts (13.0% vs 27.3%; P=.01). In multivariable models that included specialty training and caseload, physicians with caseloads of 20 to 49 and >50 were more likely to have a high knowledge score (defined as 80% or more correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P <.001, respectively), and the effect of specialty was attenuated (OR, 2.7; P=.02 decreased from OR, 7.8; P <.001 in a model without caseload). In the models predicting referral practices, both experience (OR,.25; P <.01 and OR,.17; P <.01 for caseloads of 20 to 49 and >50, respectively) and specialty (OR,.19; P <.01 and OR,.09; P <.01 for generalist and ID experts, respectively) were significant. CONCLUSIONS: In a national sample of physicians, HIV-specific knowledge was more strongly associated with HIV caseload than with specialty training. In addition, although referral practices were related to both experience and specialty, generalist experts and ID physicians reported similar behaviors. This suggests that generalist physicians, through clinical experience and self-education, can develop specialized knowledge in HIV care.     

A situational analysis of HIV/AIDS-related discrimination in Bangkok, Thailand

Unlike its other Asian counterparts, the national prioritizing of HIV/AIDS in Thailand, through the development of a number of preventive initiatives, has resulted in a declining rate of incidence. While there are no laws overtly protecting the rights of people living with HIV/AIDS (PLWHA), substantial written policy has been enacted. Yet in spite of this highly protective legislative and policy environment, discrimination against PLWHA continues to occur in practice. Focusing on the healthcare sector, through the framework set out in the UNAIDS 'Protocol for the Identification of Discrimination against People Living with HIV' (the Protocol) this study found that discriminatory attitudes and practices arose primarily due to a lack of appropriate monitoring of levels of compliance by health care providers. The disparity between written policy and practice can be explained by the underlying personal and cultural factors and the authors strongly contend that for written policies to effectively work, further research needs to be conducted into the individual and cultural values of Thai health personnel.     

Osteomyelitis: Etiology, Diagnosis, Treatment and Outcome in a Public versus a Private Institution

BACKGROUND: Although bone infections are difficult to diagnose and manage, primary health care providers often give comprehensive care to patients with few referrals. To evaluate how trends in care impact upon management of bone infections, we performed a retrospective review of medical records of 198 osteomyelitis patients. PATIENTS AND METHODS: 130 patients were hospitalized at a private institution and 68 were hospitalized at a public (teaching) institution. Outcomes measured were bone salvage or loss in relation to predisposing co-morbidities and infectious disease (ID) physician involvement in the patient care. RESULTS: Co-morbidities predominating at the public and private hospitals, respectively, were presence of metal implants (20% and 37%) and diabetes (32% and 31%). The most common pathogens at the public and private hospitals, respectively, were methicillin-susceptible Staphylococcus aureus (MSSA, 16 and 32%) and methicillin-resistant S. aureus (MRSA, 3% and 31%). ID specialists treated longer with i.v. antibiotics (42 and 43.5 median treatment days) than non-ID specialists (14 and 7 median treatment days). When ID specialists were involved in case management, a trend to bone salvage was seen at the public hospital (p < 0.09). CONCLUSION: Osteomyelitis patient outcome varies less by hospital setting than by case management.     

The effects of a social-cognitive method based education on knowledge and attitudes intentions with respect to HIV transmission among students in Maragheh,Iran

Objective

To evaluate a social-cognitive method based HIV/AIDS prevention education among students in high schools of a small city in Maragheh, Iran.

Methods

The study was based on a pre-post-quasi experimental design; pre-experimental questionnaires were administered among a total of 369 students chosen from 10 different high schools. We used a validated, self-administered questionnaire as the research instrument. The questionnaires examined validly and reliably with Cronbach''s alpha test (83%). Students were randomly divided to the general physician intervention group and the specialist intervention group for gaining the social-cognitive method based HIV/AIDS prevention education. After two months, the post-experimental questionnaires were administered among the same students.

Results

The mean score of educational pre-experimental questionnaires was 10.127 4, and the mean score of post-experimental questionnaires was 12.430 9. The difference was significant (P<0.001). On the other hand, the attitude pre-experimental questionnaires mean score was 50.804 3, and the post-experimental questionnaires mean score was 51.744 6, the difference regarded to attitude was not significant (P>0.055).

Conclusions

Although the social-cognitive method based education was not associated with a change in students'' attitude about HIV/AIDS prevention, but was associated with higher knowledge in this regard. Peer group education, condom promotion and useful and productive life skills taught by trained experts are needed to educate the high school students regarding the health consequences of HIV/AIDS for having a significant effect on their attitude.     

Addressing smoking among people living with HIV: a cross-sectional survey of Australian HIV health practitioners’ practices and attitudes

People living with HIV (PLHIV) have high rates of tobacco smoking, and smoking is a leading cause of premature mortality and morbidity. It is important to understand HIV healthcare providers’ practices and attitudes towards addressing smoking with their patients. An online survey that measured: (i) use of the 5A framework for addressing smoking (Ask, Assess, Advise, Assist, Arrange) and (ii) attitudes and barriers to addressing smoking cessation was distributed by relevant professional bodies. Eligible participants were Australian health practitioners providing healthcare to PLHIV. Of the 179 respondents, most reported practising at least one of the 5As: Ask (94%); Assess (78%); Advise (82%); Assist (89%); and Arrange (73%). Practising the full 5A framework (completing at least one activity from each A) was less common (62%) and associated with having undertaken smoking cessation training (OR 2.1, CI 1.1–3.9), being a medical practitioner (OR 6.0, CI 3.1–11.6), having greater perceived knowledge and resources (OR 1.7, CI 1.3–2.4) and more positive attitudes (OR 1.5, CI 1.1–2.0). Common barriers to delivering cessation assistance related to knowledge and availability of resources. Development and greater dissemination of effective smoking cessation training and resources may be required to ensure healthcare practitioners have the capacity to complete all aspects of the 5A framework for smoking cessation and support their patients with HIV who smoke.     

Violence against women: knowledge and attitudes of the the medical staff at the Mexican Institute of Social Security, Morelos, Mexico

OBJECTIVE: To asses the affective, cognitive, and behavioral attitudes of healthcare providers at the Mexican Institute of Social Security (MISS) in Morelos, Mexico; to identify the institutional and medical practice barriers that hinder screening and reference of battered women. MATERIAL AND METHODS: A cross-sectional study was conducted between September and December 1999. A self-administered questionnaire was applied to 269 general practitioners, specialists, and pre- and postdoctoral students working in 30 primary and secondary level of healthcare units in Morelos State. The data collection instrument was designed to assess healthcare providers' knowledge of and attitudes towards domestic violence during medical office visits. A knowledge index was constructed and analyzed using multivariate regression methods. RESULTS: Ninety percent of healthcare providers had never received training on violence against women. Healthcare providers' affective and cognitive attitudes after receiving training on the subject matter were more favorable compared to those with no training. Favorable attitudes were directly related to the number of training sessions. Most participants (63%) showed a moderate degree of knowledge on the subject, whereas 21% were slightly knowledgeable and 16% were highly knowledgeable. Medical personnel with a moderate or high level of knowledge were 2.1 and 6 times more likely, respectively, to have favorable attitudes than those with a low degree of knowledge. Female physicians showed more favorable attitudes towards identifying and referring battered women. Medical personnel interested in further training on the subject of violence against women were 7.6 times more likely to show favorable attitudes than personnel not interested on the subject. CONCLUSIONS: Healthcare providers were not sufficiently able to assess and manage battered women. General and family practitioners were more interested in being trained, as compared with specialist physicians. Training on violence against women should be included in graduate medical, nursing, social service, psychology, and other public health areas. The English version of this paper is available at:http://www.insp.mx/salud/index.html.     

Prenatal HIV counseling,testing, and antiretroviral prophylaxis by obstetric and family medicine providers in Alabama

BACKGROUND: The study reported here assessed the implementation of recommendations for routine universal prenatal counseling and voluntary HIV testing among Alabama physicians who provide prenatal care and determined factors associated with noncompliance. METHODS: Voluntary, confidential mailed survey of obstetrics and family medicine practitioners. RESULTS: Of the 138 physicians who responded to a mailed survey in Alabama, 17 (12.3%) indicated that they did not offer universal HIV counseling and testing to pregnant women. Factors associated with failure to offer universal HIV counseling and testing included having more than 50% of patients refuse HIV counseling and testing when offered and never knowingly having given prenatal/perinatal care to women with HIV. Low/medium familiarity with the US Public Health Service recommendations for perinatal zidovudine use to reduce HIV transmission and physician specialty are also suggested as predictors of not offering universal testing. CONCLUSIONS: Despite the well-established benefits of antiretroviral prophylaxis to prevent vertical transmission of HIV, some physicians in Alabama have been slow to adopt universal testing of their pregnant patients for HIV in the prenatal period. Practitioner education is as important as patient education in eliminating pediatric HIV in the Deep South.     

PrEP Awareness,Familiarity, Comfort,and Prescribing Experience among US Primary Care Providers and HIV Specialists

HIV pre-exposure prophylaxis (PrEP) was FDA approved in 2012, but uptake remains low. To characterize what would facilitate health care providers’ increased PrEP prescribing, we conducted a 10-city, online survey of 525 primary care providers (PCPs) and HIV providers (HIVPs) to assess awareness, knowledge, and experience with prescribing PrEP; and, comfort with and barriers to PrEP-related activities. Fewer PCPs than HIVPs had heard of PrEP (76 vs 98%), felt familiar with prescribing PrEP (28 vs. 76%), or had prescribed it (17 vs. 64%). PCPs were less comfortable than HIVPs with PrEP-related activities such as discussing sexual activities (75 vs. 94%), testing for acute HIV (83 vs. 98%), or delivering a new HIV diagnosis (80 vs. 95%). PCPs most frequently identified limited knowledge about PrEP and concerns about insurance coverage as prescribing barriers. PCPs and HIVPs differ in needs that will facilitate their PrEP prescribing. Efforts to increase PrEP uptake will require interventions to increase the knowledge, comfort, and skills of providers to prescribe PrEP.     

Physician specialization and antiretroviral therapy for HIV

BACKGROUND: Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection. OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART). DESIGN: Observational cohort study of patients under care for HIV infection and their physicians. PATIENTS AND SETTING: This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians. MEASUREMENTS: Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor. RESULTS: Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations. CONCLUSIONS: Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.