By the end of 2012, an estimated 21 405 persons were living with HIV infection in the Houston metropolitan statistical area (MSA).¹ The Houston MSA accounts for more than 30% of reported cases of HIV infection in the state of Texas² and ranks 12th nationally among MSAs for persons living with HIV infection.³ Advances in antiretroviral therapy (ART) and medical care have led to increased survival for patients living with HIV,^4-8 resulting in an increased number of patients requiring care. Treatment of HIV disease involves making complex decisions about ART, coordinating medical care, managing comorbid conditions, and linking patients to supportive services. As the medical needs of patients with HIV have evolved, so have the demands placed on their providers and the health care workforce to provide high-quality care. This has led to a high volume of patients being referred for management of comorbidities and providers possibly having less time to discuss transmission risk reduction interventions with patients.⁹

There are more HIV providers retiring or leaving practice than there are new ones entering the field. A 2011 Institute of Medicine report raised concern about a lack of experience among HIV providers and cited a paucity of data about the training and qualifications of providers.¹⁰ Current HIV treatment guidelines indicate that ART be considered for all patients, regardless of CD4 count.¹¹ Although scientific evidence supporting ART in the prevention of HIV has helped to expand the public health approach to include serious consideration of the clinical and preventive benefits of treatment for individuals and their communities,^7,12-14 much remains unknown about the current HIV care delivery system and the ability to deliver such benefits. A system for monitoring adoption and implementation of HIV treatment guidelines by providers, clinical interventions to prevent transmission, and overall evaluation of public health focus is lacking.

A number of organizations, including the US Centers for Disease Control and Prevention (CDC), have suggested that evolving productivity standards that support quality care by HIV clinicians should reflect the complexity and intensity of HIV care and allow providers adequate time to monitor and manage the patient’s medical care needs and provide oversight of comorbidity management.^13,15 The growing and complex trajectory of HIV and its related disease burden has raised new challenges for health care providers and systems.¹⁶

The patient–provider relationship is privileged and complex. In today’s health care system, where delivery involves numerous interfaces as clinicians manage patient care, the patient–provider relationship has proven to be central to effective primary care and chronic disease management.^17-19 An ongoing and consistent relationship between patients living with HIV and their providers helps to establish open communication and trust and has been associated with better medication adherence rates, patients’ acceptance of treatment, and support service recommendations.^20-22 Patients who report that their physicians exhibit patient-centered communication behaviors are significantly more satisfied with their care^23-25 and report greater improvement in general medical conditions.²⁴

Ascertaining information about clinicians who provide HIV care, providers’ perceptions of patients, and the factors that influence their care decisions is not commonly done. We describe HIV care providers’ sociodemographic and medical practice characteristics, the type of health care services offered to patients, and provider–patient interactions during medical care encounters in Houston/Harris County, Texas.

The increased prevalence of persons living with HIV is resulting in an increased demand for primary health care services and shortages of the HIV medical workforce. The findings indicate that slightly over half of the HIV care providers were of age 45 or older, with more than 10 years of HIV care experience, suggesting that most started practicing between 1981 and 2000. According to the Health Resources and Services Administration (HRSA), more than a third of US physicians in practice are aged 55 or older and are likely to retire in the next 10 to 15 years.³² There is an estimated current shortage of 7000 primary care physicians in underserved areas.³² Because more HIV providers are leaving their practice without a sufficient pool of new providers to take their place,^10,33 this may result in provider providers shortage that could impact the quality of care received by persons living with HIV. Almost 40% of the providers in our sample reported that they see at least 100 HIV-positive patients per month. Although not statistically significant, an increased number of patients seen at these clinics were associated with providers’ increased years of practice experience. Increase in HIV caseloads ranging from 25% to 90% have already been reported by many HIV physicians over the last couple of years.^32,34,35 In a national survey of physicians, size of HIV care practice has been more strongly associated with HIV-specific knowledge than with specialty training.^36,37 Although HIV care providers in our sample self-rated themselves as being either very or extremely knowledgeable in HIV care, we did not find any association between HIV-specific knowledge and number of patients they cared for in their clinics.

Approximately 60.9% of our study participants were board-certified infectious disease physicians. This proportion is similar to the 59% reported in national provider survey data.²⁹ However, the reality is that the management of HIV disease necessitates both specialty and primary care expertise. It has been estimated that primary care physicians comprise a large proportion of physicians who care for persons living with HIV.^32,37 Physicians of color, particularly blacks and Hispanics/Latinos, are greatly underrepresented among the HIV care providers in Houston/Harris County, Texas. Our study indicates that more than 70% of the patients cared for are minority, whereas over half of the providers in Houston/Harris County are white. The HIV Medical Association (HIVMA) similarly noted a severe shortage of minority physicians in the field of HIV.³⁸ To alleviate this problem, HRSA is currently developing resources for providers to enter HIV/AIDS care as well as strategies to extend the capacity of the existing health care workforce.³²

Houston is one of the most culturally and ethnically diverse cities in the United States.³⁹ We noted that slightly over half of the HIV care providers used languages other than English to administer care to their patients. Access to language-concordant physicians by patients has been effective in reducing reports of adverse medication effects and confusion with medication instructions.⁴⁰ This finding offers credence to having a system that will enhance the language proficiency of the health workforce and help to reduce language barriers to HIV care within the health care system.

A higher proportion (P < .05) of white than black patients visited private providers than public providers for HIV care. This finding may be associated with the diversities in unemployment, uninsurance, or underinsurance among minorities, especially blacks,⁴¹ causing more HIV-infected individuals to rely on Ryan White HIV/AIDS Program-funded clinics and safety net HIV providers such as community health centers and public hospitals that offer free HIV care. The finding that a high proportion of MSM (53%) received HIV care may be an indication of the disproportionate burden borne by this subgroup in Houston/Harris County.⁴²

Slightly over two-thirds of HIV care providers in our sample offered HIV screening to all their patients aged 13 to 64 years. This figure is slightly higher than the 60% observed at the national level.²⁹ Several barriers to HIV screening among physicians such as insufficient time, burdensome consent process, lack of knowledge/training, lack of patient acceptance, pretest counseling requirements, competing priorities, and inadequate reimbursement have been identified by Burke et al.⁴³ McNaghten et al²⁹ found that younger physicians were more likely than their older counterparts to offer HIV testing to their patients, and they attributed this to training on HIV testing, diagnosis, and treatment. This may explain in part our finding, since majority of our participants were relatively older and experienced HIV care providers. Implementation of routine HIV testing by health care providers presents an opportunity to diagnose HIV early in the course of disease, link infected persons to care and treatment and encourage reduction in risky sexual behaviors and prevent new infections.^29,44,45 For these reasons, the National HIV/AIDS Strategy has focused public health efforts on the HIV care continuum, from diagnosis to linkage to care and ART.⁴⁶

HIV care providers in our study reported that on average, one-fifth of HIV-positive patients missed their scheduled clinic appointments. Our finding supports earlier study outcomes where 20% to 40% of recently diagnosed patients missed out-patient clinic appointments.^47,48 Patients with regular clinic visits are more likely to receive comprehensive care including preventive care, reducing the frequency of hospitalizations and emergency department visits, and decreasing overall health care expenditures.⁴⁷ We also noted that private HIV care providers spent more time with patients new to care than do those in the public settings. This finding may be related to the fact that most public clinics use an integrated care model, where coordinated access to subspecialty care needs and services are available, thus providers can address immediate clinical needs in less time.

Our study revealed that about 74% of HIV care providers reported that majority of people living with HIV seek HIV care only after experiencing symptoms, leading to late diagnosis and treatment. Among those initially diagnosed with HIV infection during 2009, one-third was diagnosed with AIDS within 12 months, indicating they were likely infected for many years without knowing it.⁴⁹ Late diagnosis contributes to mortality and morbidity and suggests missed prevention opportunities.^50,51 The most commonly cited reason for delaying care among HIV-positive patients in Houston/Harris County was fear (42%) followed by denial (35%) and not feeling sick (34%).⁴² Delayed entry into care and intermittent care can lead to poor clinical outcomes, development of drug-resistant virus, and transmission of HIV to others.⁵² Retaining HIV-infected patients in medical care at regular intervals have been shown to be linked to positive health outcomes.⁵³

No referrals were made for identified medical services by the majority of HIV care providers in our study. This may be an indication of greater HIV experience and expertise as their practice years averaged 11.7 years, with 61% of the providers identifying as board-certified infectious disease physicians. It was interesting to note that all of the participating HIV care providers in the Houston/Harris County reported that persons living with HIV can easily obtain care. This finding supports the Houston Area Ryan White Planning Council needs assessment survey outcomes in which patients were asked about their experience accessing available Ryan White HIV/AIDS Program core medical services.⁴² In this survey, 74%, 68%, and 63% of patients identified the top 3 services as primary medical care visits, HIV medications, and case management, respectively, and asserted that these services were all very easy obtain.

Most (91.3%) of the providers in our study reported that they provide care to patients who receive ADAP and those enrolled in the Medicare Prescription Drug Benefit plan and that these programs significantly (P ≤ .01) provide for patients’ treatment and medication needs. Since 1992, HRSA through the Ryan White Grant Administration has awarded and administered over US$300 million in funding to health and social service agencies in the Houston Eligible Metropolitan Area (EMA).⁵⁴ The flexibility afforded by Ryan White funding in filling the coverage gaps has been critical to helping many persons living with HIV find medical care homes in the Houston EMA.

HIV medical care providers stated that they “always discussed” certain health topics and preventive measures with patients new to HIV care and only “sometimes” or “almost never discussed” them with established patients. The most discussed topics with both groups were “adherence to ART,” “how to take medicines,” “ART side effects,” and “family/social support.” Although the topics discussed likely differ from one patient to another depending on the scenarios and associated health needs, shared decision making can increase patient engagement in care, help reduce HIV transmission risk and improve ART adherence.⁵⁵

Given the IDSA/HIVMA HIV primary care guidelines,¹⁶ for achieving HIV viral suppression, and the current emphasis of treatment as prevention, adherence to ART has become even more critical. Our study recorded a much higher proportion of HIV care providers (91.3%) who consistently discussed adherence to ART regimen with patients new to HIV care who were prescribed ART compared to 87% of MMP providers reported at the national level.⁵⁶ However, the proportions of HIV care providers who reported consistent discussion of preventive care with new and established HIV-positive patients in the 3 integrated areas (HIV transmission risk reduction, partner counseling services, and discussions of STD risk),¹⁵ in our study were low to moderate. Thus, there is cause for concern, given the emphasis on prevention activities for HIV-infected persons reflected in the National HIV/AIDS Strategy for the United States,⁴⁶ and the central role of HIV care providers in this effort. For instance, care providers who agreed to consistently discussing partner counseling services with new and established patients were only 21% and 8%. Referral to partner counseling services is crucial for preventing new infections in sex partners who are not infected and for ensuring that infected partners promptly receive HIV care.⁵⁶ In summary, the ultimate aim of incorporating HIV prevention into the medical care of people living with HIV is to implement a safer sex program that will instill self-protective and partner-protective motivations for reducing risk behaviors over time.

It is important to assess providers’ prevention counseling practices and determine how best to promote these practices in order to reduce high-risk behaviors among persons living with HIV. Our current study indicates that a significant proportion of HIV care providers may benefit from additional trainings. Consequently, training on brief risk screening methods that do not require much of providers’ time and brief risk-reduction interventions can enhance comfort, skills, and motivation of providers.⁵⁷ The AIDS Education and Training Centers,⁵⁸ which operate nationwide, provide excellent education and training programs for health care providers treating persons living with HIV/AIDS and can be instrumental for this purpose.

The majority of the HIV medical workforce in Houston/Harris County is composed of HIV clinicians who entered the field in the early years of the epidemic. As these clinicians retire without replacements, the HIV care system may face a crisis in care capacity.³⁸ This study suggests that concerted efforts may be needed by government, professional health care schools, and organizations to recruit, educate, and retain clinicians in the field. Since Houston/Harris County is culturally and ethnically diverse with minorities comprising a greater proportion of the overall population, there is absolute need for more diverse, multilingual, and culturally competent HIV care providers workforce to cope with the increasing demand for health care services in the community. In addition, the high proportion of persons being diagnosed with AIDS within 12 months of HIV diagnosis suggests that increased access to both routine and targeted HIV testing is needed to ensure early diagnosis of HIV and subsequent reduction in the proportion of people unaware of their HIV status. Adherence to USPHS screening guidelines by HIV care providers, facilitation of primary care linkage, and the development of a consistent set of measures to examine retention in care are critical first steps for improving the health of persons living with HIV.