The Genie Is Out of the Bottle: Telemedicine Is More Effective Than Brick-and-Mortar Clinics in the Care of HIV-Infected Outpatients

Introduction

A new era in the care of individuals infected with HIV was ushered in upon the arrival of the COVID-19 pandemic in 2019-2020. Many individuals with HIV feared that coinfection with severe acute respiratory coronavirus 2 (SARS CoV2) might be more severe coupled with their HIV infection and were understandably reluctant to attend clinic in-person. Mandatory masks and social distancing were implemented in February 2020 and thereafter. Soon outpatient visits to brick-and-mortar clinics were canceled or curtailed for many medical care specialties. Our health care organization implemented telemedicine clinics in April 2020. Because our group had been providing telemedicine for infectious disease to the county jail and the Arizona Department of Corrections (∼45,000 incarcerated individuals) since 2006, we rapidly adapted our telemedicine model of care, making it available for all outpatients with HIV in the community (they were formerly served only by brick-and-mortar clinics). Implementation of telemedicine clinics during the pandemic has been shown to be effective for ambulatory patients infected with HIV.1, 2, 3 We scheduled outpatients for either telemedicine or brick-and-mortar clinics through most of 2020. Due to lockdowns, we offered only telemedicine clinics for all of 2021. However, beginning in January 2022 patients infected with HIV were given the choice of attending telemedicine or brick-and-mortar clinics. In this report we compare telemedicine clinics with brick-and-mortar clinics, measuring medical outcomes, cost-effectiveness, time management, and patient and employee acceptance of the clinics. Careful analysis demonstrated that telemedicine performed better than brick-and-mortar clinics in all categories.

Notwithstanding the real gains made in health care by widespread use of telemedicine (with successful outcomes such as enumerated here), there is the risk that all will be lost in the haste to return to pre-COVID-19 medical care routines. Health care organizations have strong organizational and economic reasons for returning to brick-and-mortar clinics rather than continuing telemedicine clinics. We hope our findings will convince caregivers to pursue offering a wide array of telemedicine clinics. Telemedicine is a first choice for many patients with long-term health problems like HIV infection.

Materials and Methods

Brick-and-Mortar Clinic

Clinics were conducted in a large multistoried building in Tucson, Arizona, served by the city bus line and offering free valet parking. Multiple specialists used the clinic space serving hundreds to thousands of patients a day. Radiology and laboratory services were available on site. The following personnel were present for patient encounters: physician, HIV pharmacist, HIV clinic coordinator, a nurse, 2 medical assistants, and 2 clerks to check-in patients. Three to 4 examination rooms were reserved for the physician.

Telemedicine Clinic

This clinic was conducted by participants from their offices by linking to a HIPAA-compliant virtual clinic. Patients joined the physician, pharmacist, and clinic director by computer or cell phone.

Patients

All patients had HIV established by antibody testing and HIV-1 viral load. Patients were enrolled in the Petersen HIV Clinics at Banner-University Medical Center, Tucson, i Arizona. At any one time the program assists in the care of more than 1000 patients with HIV. Multiple daily clinics are sponsored by the program, each attended by an infectious diseases physician, HIV pharmacist, and HIV clinic coordinator. Patients described in this report were served by 1 physician who founded the clinic in 2000. All patients were required to have a primary care physician for health maintenance. Patients were seen at least once a year and antiretroviral therapy (ART) was prescribed for 1 year. Sexually transmitted disease laboratory specimens were obtained as needed and twice-yearly HIV-1 RNA PCR and yearly CD4 T-cell count were performed as required per protocol.

Role of Telemedicine Clinic Personnel

The physician was responsible for the conduct of the visit and medical outcome. A history was obtained, an appropriate review of systems conducted, and a plan made for future clinic visits. The physician was responsible for billing based on time and complexity. The pharmacist was responsible for assessing medication adherence, addressing medication-related adverse effects, reviewing drug interactions, evaluating lab testing, and ensuring patients were up to date on immunizations. The clinic coordinator was responsible for hosting the virtual session, inviting appropriate staff, coordinating/coaching patients to ensure they could successfully log in, and monitoring the time to prevent the clinic from running late. During the appointment, the clinic coordinator screened for socioeconomic barriers such as financial hardship, behavioral health conditions/substance use disorders, health insurance coverage, and medication copays. The coordinator performed a sexual health assessment and offered testing for sexually transmitted infections (STIs) testing at-risk patients. Swabs were mailed to patients to test for oral/rectal gonorrhea or chlamydia. The clinic coordinator scheduled a follow-up appointment, ordered future lab work, and obtained permission to email or text follow-up information.

Data Collection

Data was retrieved from a HIPAA-compliant electronic medical record and deidentified. All clinic visits for the physician since August 2019 were scrutinized. Pertinent laboratory values were recorded, and encounter documentation abstracted.

Results

Patient Characteristics

The outpatient population with HIV is similar to other HIV clinics in the Southwest. It is 1 physician's panel accumulated over 22 years. The patient demographic characteristics were similar to those for the entire state of Arizona.⁴ The sex incidence and risk factors for HIV (Table 1) were also similar to the state of Arizona data with the exception that patients with a history of intravenous drug use were fewer in the clinic than what occurred statewide.

Table 1.

Patient Characteristics

Characteristic	Category	N (percentage)
Sex	Men	113 (84%)
	Women	21 (16%)
Risk Factor for HIV	MSM	103 (71)
	Heterosexual	33 (23)
	IVDU*	4 (2)
	Congenital	2 (1)
	Bisexual	2 (1)
	Unknown	1 (1)
Years living with HIV	0-5 years	16%
	5-10 years	21
	10-20	24
	>20	39%

^⁎HIV = human immunodeficiency virus; IVDU = intravenous drug user; MSM = men who have sex with men. Patients attending the telemedicine and brick-and-mortar clinics January through July 2022. There were 134 unique patient visits and 9 return visits within the 7-month period.

The clinic population has aged as can be inferred from Table 1 where nearly 40% of attendees have lived with HIV for more than 20 years. Aging of our clinic patients has been apparent for years.⁴ Petersen Clinic data shows that the ethnic identities are similar to Arizona statewide data.⁵ There is no reason to believe that our population of patients would be unique in their approach and response to telemedicine services; thus, data from this study are likely similar to many other HIV clinics in the US.

Medical Encounters

There were 974 encounters with patients with HIV during the 3-year period, 670 by telemedicine and 304 in person. Clinic visits up until the second quarter of 2020 were brick-and-mortar at which time telemedicine clinics became available. Telemedicine was the only venue available venue for all of 2021 (Figure 1 ).

Figure 1.

Number of patients attending telemedicine (grey columns) and brick-and-mortar (orange columns) clinics by quarter of year (3 months).

January through July 2022 patients were given the option to choose their preferred clinic venue. We studied these encounters in detail. During 2022, 151 patients were scheduled to attend 20 telemedicine clinics and 143 patients showed (show rate, 94.7%). A total of 14 of the 20 clinics had a 100% show rate. There were 9 return visits in that period. Contrarily, for the brick-and-mortar clinic, 33 patients were scheduled for 4 clinics and 26 patients showed (show rate, 78.7%), and no clinic had 100% attendance (Figure 2 ).

Figure 2.

Percentage of patients showing for appointment (showed/scheduled). Telemedicine clinics (grey columns) and brick-and-mortar clinics (orange columns) by quarter of year (3 months).

Even these numbers underestimated the number of patients preferring telemedicine because health care organization employees called many patients mistakenly informing them that only brick-and-mortar clinics were available. Nevertheless, patients overwhelmingly chose to attend the telemedicine venue.

Medical Outcomes

All but 6 visits during 2022 involved patients with sustained viral control (viral load <200 copies HIV RNA/μl). In all, 4 of those 6 visits involved patients being seen for the first time or who had their ART interrupted and had viral loads in the thousands. These 4 patients were begun on, or returned to ART, and viral loads were undetectable within several months. Two patients, followed over years, had measurable viral loads >200 copies of RNA/μl because of noncompliance with ART. It is pertinent to note at this point that most of the telemedicine encounter time with patients was spent reinforcing medication compliance, arranging vaccine administration and future laboratory visits, rather than medical issues per se. Nevertheless, there were a few encounters as shown in Table 2 where other diagnoses were made.

Table 2.

Diagnoses Made at HIV Telemedicine Visits, First 6 Months of 2022

Disease	Number of Cases
Syphilis	7
Drug rash	3
Dermatophyte infection	3
Chlamydia	2
Herpes genitalis	1
Tinea versicolor	1
Steroid acne	1
Henoch-Schoenlein purpura	1
Diabetic ketoacidosis	1
Gonorrhea	1
Pneumocystis pneumonia*	1

^⁎Died following hospitalization.

Skin lesions were viewed on video, and in conjunction with the history and symptoms, it was not difficult to diagnose Henoch-Schoenlein Purpura, steroid acne, and dermatophytosis. The diabetic ketoacidosis was diagnosed by history of previous ketoacidosis, lack of insulin for days, polyuria, and 4+ ketones on a dip stick test of urine.

Cost-Effectiveness

The physician, pharmacist, and clinic director were present for all encounters at both venues. However, for telemedicine clinics, a large cost savings was achieved because no physical space was required; the medical assistant, nurse, and 2 sign-in clerks were not needed nor were parking attendants and orderlies. Telemedicine personnel had cost savings as well. For example, they had no travel time or expenses, and there was less “lost” time incurred such as happens when patients fail to attend brick-and-mortar clinics.

Patient Comments

Patients chose to attend telemedicine over brick-and-mortar clinics. Comments we received may explain why they preferred the venue. Many patients commented that they experienced less stigma using telemedicine because they did not have to undergo public exposure while traveling to and waiting for their appointment. All patients were impressed by the ease with which the encounter could be achieved. Encounters occurred in patient homes, offices, automobiles, airplanes, in hospital, both inside or outside buildings, and while patients were on vacation in remote areas. Many said they felt more connected, given the ease of making appointments for telemedicine that involved no travel time. Only one patient insisted on always being seen in person.

Discussion

Despite the many promises of telemedicine, use of this modality in many medical communities has been limited to radiology and psychiatry. Other specialties turned to telemedicine usually in circumstances where great distances separated the patient from the caregiver. This was the status quo in our institution until the the COVID-19 pandemic. Prior to COVID-19, use of telemedicine in our medicine department was limited to incarcerated individuals throughout Arizona. Since 2006, a monthly or bimonthly telemedicine clinic was conducted for those with HIV infection and incarcerated. After the pandemic arrived, nearly all brick-and-mortar clinics were closed in our large hospital system. Therefore, throughout 2021 we used telemedicine only (Figure 1). Because we had been providing care to incarcerated individuals by telemedicine for years, we adapted our service for community outpatients as well. We show in this report that by any measurement, the telemedicine clinic experience was as good as, or better than brick-and-mortar clinics with respect to medical outcomes, cost-effectiveness, and time management by patients and health care personnel.

The most important factor in comparing telemedicine with brick-and-mortar clinics is the medical outcome of the visit. We found a difference between the 2 venues when considering outcomes, and it favored Telemedicine. For example, one measurement of the effectiveness of HIV care is whether HIV is controlled, meaning, individuals sustain HIV-1 RNA below 200 copies/μl. Prior to the pandemic ∼91% of our patients were controlled,⁶ whereas during 2022 that figure had risen to >98.6% when the majority of encounters were by telemedicine. Various coincident diseases were also diagnosed as readily as in brick-and-mortar clinics, especially STIs. These were addressed by regular and repeated blood sample, culture, and polymerase chain reaction of urine for patients at risk for STI acquisition determined by STI risk assessment. An important contributing factor for the preference for telemedicine by clinic personnel was that time utilization was more effective when using telemedicine where the show rate was much greater, and the clinic coordinator controlled the timing of patient encounters. A major contributing factor was that the patient show rate was much greater for telemedicine than brick-and-mortar clinics (94.7 vs 78.7%). Our findings confirm those of a recent Veterans Affairs study that demonstrated better attendance at telemedicine than brick-and-mortar clinics during the pandemic.⁷ It is obvious that telemedicine is more cost-effective for patient and employees alike. No physical space was required, no travel was involved, and fewer employees were needed. We did not attempt to put any monetary values on these differences.

In the rush to return to the comfortable routine of prepandemic times, health care organizations are discouraging the use of telemedicine. They are, however, encouraging and even mandating outpatients to return to brick-and-mortar clinics. The organizations favor brick-and-mortar clinics because they offer supervisory control and for monetary reasons. Health care organizations have built expensive physical structures and must maintain them. To do so they must maximize income and visits to a brick-and-mortar clinic. Physical space is of greater monetary value than telemedicine clinics. However, returning everything to brick-and-mortar clinics does not take into account patient needs and preferences. It is quite possible that the gains made by telemedicine in the quality of care of patients during the pandemic will be sacrificed to fiscal and administrative concerns.