This study examined choice of ART for HIV/AIDS patients among physicians in 4 states and found that general IM physicians were significantly less likely than ID physicians to choose ART that is consistent with recommendations in current guidelines.2,3,8,9
In addition, physicians with little or no previous HIV experience were also significantly less likely to choose ART consistent with current guidelines. Importantly, however, many generalists and those with less HIV experience indicated that they would have referred the patients to another physician for management of HIV. In fact, when the analysis was restricted to only those who would have managed patients with HIV themselves, smaller differences were seen in choices of appropriate medications by physician specialty and experience. These findings regarding knowledge of appropriate ART for HIV are important because it is widely acknowledged that use of this standard of care has led to substantial decreases in HIV-related morbidity and mortality due to HIV/AIDS in the United States.1,7
In addition, our findings with regard to planned referral of HIV patients by many generalists are also important, because they may serve to decrease concern about the consequences of their lower knowledge of current HIV care on the quality of care they provide.
Given how recently these guidelines have been released, it may be premature to characterize these apparent prescribing differentials by specialty and HIV experience as quality of care differences. It may be that the antiretroviral choices of general IM physicians and those with less HIV experience reflect slower adoption of antiretroviral guidelines by these physicians, not ongoing quality of care differentials. This phenomenon has been described by others regarding provision of HIV/AIDS care.21,22
One might also hypothesize that some of these physicians who did not choose recommended regimens may have chosen regimens categorized as “alternative” by the 1997 guidelines, which were 3 drug regimens containing nevirapine or saquinavir hard gel caps.8,9
Actually, choice of these “alternatives” by respondents was uncommon (6.0% for Case 1 and 4.7% for Case 2), and was significantly higher among ID physicians and those with more HIV/AIDS experience. It should be noted that the 1997 guidelines were the first to recommend triple regimens using 2 nRTIs and 1 PI for initial ART for all patients who meet criteria for treatment. While the specifics of the triple regimens have changed in subsequent guidelines,2
the changes have been subtle. Thus, physicians' ability to choose ART consistent with these recommendations remains relevant to current antiretroviral prescribing and HIV care.
The question of whether generalists are as knowledgeable and provide comparable care to specialists has generated a considerable amount of interest and research in recent years. The results of studies examining this question in several other important diseases seem to suggest that the situation is actually quite complex, regardless of whether knowledge, use of efficacious treatments, or outcomes are being examined. While several previous studies of medical treatments have found that specialists are more knowledgeable about the use of effective medical treatments,23–25
others have found that generalists' knowledge and use of these treatments is equal to or better than that of relevant specialists.25–27
The results of studies that have examined outcomes of care have been similarly mixed. The Medical Outcomes Study followed a large cohort of patients with hypertension and diabetes and found no differences in survival or quality of life among those cared for by specialists compared with those cared for by generalists.28
However, studies of the inpatient care of those with acute myocardial infarction29
found they had lower mortality when the admitting physicians were specialists (cardiologists and neurologists, respectively). In summary, these data examining the care provided for other important diseases suggest that specialists at times use optimal management options more than generalists, and sometimes they do not.
Few previous studies have examined the knowledge, outcomes of care, or use of indicated treatments by generalist physicians in the care of HIV/AIDS patients.10,16,31–33
More than a decade ago Northfelt and colleagues argued that HIV disease was becoming a “primary care disease.”34
Their view was that HIV was a common chronic disease like hypertension and diabetes, and would be seen in primary care settings. They further stated that primary care physicians should, therefore, be prepared to manage HIV and required certain basic HIV-related clinical skills. Briefly, these included skills in HIV testing and counseling, skills in HIV treatment and prophylaxis to prevent opportunistic infections, and skills in recognizing and managing key HIV-related clinical problems. Recently, Hecht et al. reviewed and summarized the available evidence regarding generalists' HIV-related knowledge, processes of care, and outcomes of care.17
They assert that there is growing evidence that many primary care physicians have weaknesses in each of the areas of importance delineated by Northfelt. Specifically, there is evidence that primary care physicians do not routinely screen their patients for HIV35
and may not have skills to adequately assess HIV risk and decide when screening is indicated.36
Also, there is evidence that many primary care physicians cannot recognize and diagnose Pneumocystis carinii
or recognize and provide care for other HIV-related problems.31
Importantly, however, the vast majority of previous studies comparing HIV/AIDS care or knowledge of generalists to specialists have focused on physician HIV experience as the key indicator of HIV expertise, not specialty. This may be in part because there is controversy about the relevant subspecialty for AIDS care, i.e., whether ID specialists have a unique role as the relevant specialists in the care of HIV/AIDS patients.17
However, based on the results presented here, it appears that the effect of specialty on HIV prescribing may be greater than the effect of HIV experience. These results provide further evidence that primary care physicians have weaknesses in the key areas of importance delineated by Northfelt, specifically, prescribing current ART.
Several recent reviews and editorials have tackled the controversy regarding whether HIV/AIDS is still a disease that can be cared for effectively by primary care physicians.17,37,38
In fact, based on the data presented here, generalists in several high HIV prevalence states may not be prepared to provide state-of-the art care for those with HIV/AIDS. However, this study provides important new insights regarding generalists and HIV care. First, it should be emphasized that the generalists with moderate to high HIV experience in this study had high levels of knowledge and apparent “prescribing practices” which were in line with current standards, and essentially equivalent to those of the ID physicians in the study. Additionally, based on these results, it appears that physicians, including generalists and those with less HIV experience, who would choose to prescribe antiretrovirals are prepared to do so. Similarly, at least in this study, those who need to seek consultative input about HIV care also appear to be aware of their need to seek such input. The recommendation that primary care physicians obtain consultative input from an HIV expert when caring for HIV/AIDS patients is articulated quite clearly in the current DHHS guidelines3
and has been echoed by others.17,37
This study provides new evidence that this recommendation is indeed appropriate.
This study has several important limitations. The results reported here are based on physicians' responses to hypothetical cases only and, thus, may not be reflective of actual antiretroviral prescribing in clinical practice. This study is also somewhat limited by response rate; only slightly more than 50% of eligible physicians responded, and there was a differential response rate by specialty, with ID physicians significantly more likely to respond than IM physicians. Therefore, it is possible that our results may be influenced by response bias. We hypothesize, however, that respondents in both specialties generally tend to be more interested in the survey subject than nonrespondents and, therefore, are probably more knowledgeable. Thus, any difference detected in knowledge by specialty and other key characteristics may have been more pronounced if the response rate had been higher.
In summary, this study reconfirms the importance of HIV/AIDS experience in physicians' effectiveness in the management of patients with HIV/AIDS. The results reported here suggest that appropriate antiretroviral prescribing is strongly related to physician HIV/AIDS experience. These data build on prior research showing that survival, utilization, and use of key preventive services are related to physician HIV/AIDS experience.10,15,32
In addition, these data demonstrate that as of mid-1998, ID physicians appear to be more likely than general IM physicians to provide ART which meets the current standard of care, based on recent guidelines. However, it appears that many physicians who are less knowledgeable about HIV/AIDS are aware of their lack of knowledge and would seek help from colleagues with expertise in HIV/AIDS when caring for these patients. These results lend support to the recommendation that primary care physicians obtain expert consultative input when caring for HIV/AIDS patients, but suggest that these physicians are able to gauge their own HIV competency and determine when there is a need for consultation.