To the Editor—We read with great interest the research article from Gallant et al, which demonstrated that comorbidities are common among the aging human immunodeficiency virus (HIV)–infected population and have increased over time [1]. In this case-control analysis, >46 million individuals living with HIV in the United States who received healthcare coverage from commercial, Medicaid, and Medicare payers during 2003–2013 were identified. Diagnoses of hypertension, dyslipidemia, and endocrine disorders were common, and comparison of data from 2003 to 2013 indicated significant increases in prevalence of comorbidities despite payer. This study highlights the importance of the identification and management of noncommunicable diseases among HIV-positive individuals; however, the methods by which to ideally manage these comorbidities in this particular population have yet to be discovered. To provide further insight to this topic, we present a retrospective analysis exploring the relationship between provider type and chronic comorbidities for HIV-positive individuals ≥40 years old (n = 919) with Medicare or commercial healthcare at an HIV clinic, the UCLA Center for Clinical AIDS Research and Education, in 2016.
Our objectives were to compare rates of monitoring and measures of quality of care among HIV-positive individuals with hypertension, type 2 diabetes, and/or hyperlipidemia by provider type: infectious diseases (ID) physician only or an ID physician and primary care physician (PCP). Patients were divided by provider type into 3 groups: (1) ID physician at the HIV clinic, (2) ID physician and PCP at the HIV clinic, and (3) ID physician at the HIV clinic and external PCP. Diagnoses of hyperlipidemia, type 2 diabetes, and/or hypertension were identified from medical records. We evaluated outcomes of comorbidities, including low-density lipoprotein cholesterol (LDL) level, hemoglobin A1c level, and blood pressure. Optimal control of hyperlipidemia, diabetes, and hypertension was defined as an LDL level of <100 mg/dL, a hemoglobin A1c level of <7.0%, and a blood pressure <130/80 mm Hg, respectively. Bivariate and multivariate statistical analyses were conducted with χ2 analysis, the Mann-Whitney U test, and logistic regression analyses as appropriate.
Individuals were predominantly male (93.1%) and white (72.0%; Table 1). One hundred sixty-eight (18%) had an ID physician only, 405 (44%) had an ID and PCP at the HIV clinic, and 343 (37%) had an ID physician at the HIV clinic and an external PCP. Individuals who had their PCP at the HIV clinic versus an external PCP were significantly more likely to be seen for a primary care visit in 2016 (381 [94%] vs 143 [42%], respectively; P < .001). Five hundred sixteen individuals (56%) received a diagnosis of at least 1 chronic comorbidity, and those with a comorbidity were more likely to have a PCP overall (448 [60%]; P < .001). Eighty-five percent of individuals with diabetes had optimal control, and the majority of individuals with hypertension and hyperlipidemia had suboptimal control (66% and 55%, respectively). There was a trend toward a greater proportion of individuals reaching lipid targets (47.3% vs 30.3%) in those with a PCP (P = .065) and higher rates of screening for hyperlipidemia and diabetes in those who had a PCP visit in 2016 (P = .072 and P = .064, respectively). Logistic regression analysis showed a trend for individuals to have an LDL level above threshold if they had an ID physician only, compared with those having an ID physician and PCP (odds ratio, 2.12; P = .070) There were no significant differences in outcomes associated with hypertension or diabetes, based on provider type.
Table 1.
Patient Demographic Characteristics and Comparison of Health Outcomes Between Groups
| Variable | All Groups | Group 1: ID Physician Only |
Group 2: ID Physician and PCP at HIV Clinic |
Group 3: ID Physician and PCP at separate locations |
P |
|---|---|---|---|---|---|
| Patients, no. (%) | 916 (100) | 168 (18) | 405 (44) | 343 (38) | |
| Age, y, mean ± SD | 53 ± 10 | 50 ± 10 | 53 ± 10 | 53 ± 10 | <.001 |
| Male sex, no. (%) | 851 (93) | 145 (92) | 380 (94) | 317 (92) | <.241 |
| Race, no. (%) | |||||
| White | 597 (72) | 110 (78) | 268 (72) | 219 (68) | |
| African American | 106 (13) | 10 7) | 46 (12) | 50 (15) | |
| Asian | 43 (5) | 8 (6) | 19 (5) | 16 (5) | |
| Native American | 3 (0.36) | 0 (0) | 2 (0.5) | 2 (0.3) | |
| Other | 80 (10) | 12 (9) | 35 (9) | 33 (10) | |
| Non-Hispanic ethnicity | 740 (88) | 122 (86) | 341 (90) | 277 (85) | |
| Diagnosis of ≥1 comorbidity, no. (%) | 516 (56) | 68 (40) | 68 (61) | 249 (58) | <.001 |
| Hyperlipidemia, no. (%) | 327 (36) | 39 (23) | 154 (38) | 134 (39) | <.001 |
| Hypertension, no. (%) | 323 (35) | 39 (23) | 147 (36) | 137 (40) | <.001 |
| Diabetes (type I and II) , no. (%) | 150 (16) | 14 (8) | 87 (21) | 49 (14) | <.001 |
| Laboratory value, no. (%) | |||||
| LDL level >100 mg/dL | 76 (53) | 23 (69) | 72 (55) | 57 (50) | .134 |
| HbA1c level >7.0% | 30 (5) | 2 (15) | 16 (17) | 5 (11) | .703 |
| Blood pressure >130/80 mm Hg | 475 (53) | 28 (72) | 95 (65) | 90 (66) | .745 |
Abbreviations: CARE, UCLA Center for Clinical AIDS Research and Education; HbA1c, hemoglobin A1c; ID, infectious diseases; LDL, low-density lipoprotein cholesterol; PCP, primary care physician.
Our findings support the data in the study by Gallant et al, demonstrating a significant prevalence of non–AIDS-defining comorbidities among individuals living with HIV. All HIV care has historically been provided by specialists, although there is evidence that individuals with PCPs have better health outcomes, compared with those who only see HIV specialists [2]. Recent studies have explored physician’s preferences on the management of chronic diseases for individuals with HIV, demonstrating that most desire integration of HIV and primary care services. Furthermore, ID specialists may feel less comfortable treating non–AIDS-defining comorbidities, likely based on provider experience, in addition to lack of adequate clinical resources to ensure comprehensive care for patients [3–5]. Our research findings suggest that primary care services embedded within HIV clinics may improve monitoring and treatment of non–AIDS-defining comorbidities among patients with HIV infection—a vital component in the future of HIV care that could potentially decrease healthcare spending and improve healthcare outcomes among individuals living with HIV.
Notes
Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Acknowledgments. We thank Ricky Tristan and Michael Marcial, for helping us access the data, as well as Alicia Wolfs and the UCLA Center for AIDS Research= (supported by grant 5P30 AI028697), for their help in the institutional review board application.
References
- 1. Gallant J, Hsue PY, Shreay S, Meyer N. Comorbidities among US patients with prevalent HIV infection—a trend analysis. J Infect Dis 2017; 216:1525–33. [DOI] [PubMed] [Google Scholar]
- 2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83:457–502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Cheng QJ, Engelage EM, Grogan TR, Currier JS, Hoffman RM. Who provides primary care? An assessment of HIV patient and provider practices and preferences. J AIDS Clin Res 2014; 5:366. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Fultz SL, Goulet JL, Weissman S et al. Differences between infectious diseases-certified physicians and general medicine-certified physicians in the level of comfort with providing primary care to patients. Clin Infect Dis 2005; 41:738–43. [DOI] [PubMed] [Google Scholar]
- 5. Duffus WA, Barragan M, Metsch L et al. Antiretroviral Treatment and Access Studies Study Group. Effect of physician specialty on counseling practices and medical referral patterns among physicians caring for disadvantaged human immunodeficiency virus-infected populations. Clin Infect Dis 2003; 36:1577–84. [DOI] [PubMed] [Google Scholar]