Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians

Source: Ann Inter Med Nov.15, 2005 Vol.143 N.10 p.729-736

Ira B. Wilson, MD, MSc; Bruce E. Landon, MD, MBA; Lisa R. Hirschhorn, MD, MPH; Keith McInnes, MS; Lin Ding, PhD; Peter V. Marsden, PhD; and Paul D. Cleary, PhD

Background: Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide.

Objective: To compare the quality of care provided by NPs and PAs with that provided by physicians.

Design: Cross-sectional analysis.

Setting: 68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states.

Participants: The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS.

Measurements: 8 quality-of-care measures assessed by medical record review.

Results: After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P Limitations: These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes.

Conclusions: For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non–HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.

Editors’ Notes

Context

Nurse practitioners (NPs) and physician assistants (PAs) or physicians often deliver primary care to patients with HIV.

Contribution

Researchers reviewed records of 6651 patients at 68 HIV clinics to compare NPs’ and PAs’ and physicians’ quality of care. Nurse practitioners and PAs and physicians with HIV expertise performed similarly on 6 of 8 guideline-related quality measures, while NPs’ and PAs’ patients had higher rates of purified protein derivatives and Papanicolaou smears than expert physicians’ patients. Nurse practitioners and PAs performed better on 6 of 8 quality measures than generalist physicians without HIV expertise.

Implications

Experienced NPs and PAs might provide basic guideline-related care similar to that of physician experts and better than that of physicians without HIV-related expertise.

—The Editors

Author and Article Information

From the Tufts-New England Medical Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, and Harvard University, Cambridge, Massachusetts.

Acknowledgments: The authors thank Carol Cosenza, MSW, and Patricia Gallagher, PhD, of the Center for Survey Research who assisted with instrument development and survey administration; colleagues at the Health Resources and Services Administration and at the Institute for Healthcare Improvement who participated in and facilitated the Evaluation of Quality Improvement for HIV Care (EQHIV) study; and Joan Lederman, RNC, MSN, and Lois Eldred, DrPH, MPH, for reading and commenting on an earlier draft of this manuscript.

Grant Support: By the Agency for Healthcare Research and Quality (grant R-01HS10227) and Lifespan/Tufts/Brown Center for AIDS Research (grant P30A142853).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Ira B. Wilson, MD, MSc, Tufts-New England Medical Center, #345, 750 Washington Street, Boston, MA 02111; e-mail, iwilson@tufts-nemc.org.

Current Author Addresses: Dr. Wilson: Tufts-New England Medical Center, #345, 750 Washington Street, Boston, MA 02111. Drs. Landon, Ding, and Cleary and Mr. McInnes: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115-5899.

Dr. Hirschhorn: Harvard Medical School, 401 Path Drive, Boston, MA 02110.

Dr. Marsden: Harvard University, 33 Kirkland Street, Cambridge, MA 02138.

Prevalence of Transmitted HIV-1 Drug Resistance and the Role of Resistance Algorithms: Data From Seroconverters in the CASCADE Collaboration From 1987 to 2003.

Source: JAIDS Journal of Acquired Immune Deficiency Syndromes. vol.40 N.5 p.505-511 Dec 15, 2005.

Masquelier, Bernard PharmD, PhD *; Bhaskaran, Krishnan MSc +; Pillay, Deenan MPH ++; Gifford, Robert PhD ++; Balestre, Eric MPH [S]; Jorgensen, Louise Bruun MSc, PhD [P]; Pedersen, Court MD [//]; van der Hoek, Lia PhD #; Prins, Maria PhD **; Balotta, Claudia MD ++; Longo, Benedetta MD ++++; Kucherer, Claudia MD [S][S]; Poggensee, Gabriele MD [S][S]; Ortiz, Marta PhD [P][P]; de Mendoza, Carmen PhD [//][//]; Gill, John MD ##; Fleury, Herve MD, PhD *; Porter, Kholoud PhD +; on behalf of the CASCADE Collaboration

Abstract:

Objectives: To examine factors influencing the rate of transmitted drug resistance (TDR) among seroconverters, with particular emphasis on 3 widely used genotypic drug resistance algorithms.

Methods: The study used data from CASCADE (Concerted Action on Seroconversion to AIDS and Death in Europe), a collaboration of seroconverter cohorts in Europe and Canada. Genotypic resistance data were derived within 18 months of the last seronegative test or date of laboratory evidence of acute infection and before the initiation of antiretroviral therapy. The Stanford algorithm was used to analyze each individual’s nucleotide sequence. A multivariate logistic model was used to assess independent relationships between the presence of TDR and exposure category, sex, age at seroconversion, and year of seroconversion. The paper also describes 3 alternative definitions of resistance: the Stanford algorithm, the key resistance mutations defined by the International AIDS Society, and the Agence Nationale de Recherches sur le Sida (ANRS) algorithm.

Results: Forty-five of 438 patients (10.3%) seroconverting between 1987 and 2003 were infected with a drug-resistant HIV-1 variant. Forty patients (9.1%) showed resistance mutations to only 1 class of antiretroviral drugs, 2 (0.5%) to 2 classes, and 3 (0.7%) to 3 classes of antiretroviral therapy. It was suggested that individuals seroconverting later in calendar time were more likely to have TDR (relative risk 3.89 and 95% CI: 0.84 to 18.02, and relative risk 4.69 and 95% CI: 1.03 to 21.31, for 1996-1999 and 2000-2003, respectively, compared with pre-1996; P trend = 0.08). This trend was apparent regardless of the definition of TDR used. The total estimated proportion of individuals with TDR varied between 10.3% and 15.5% according to which definition was used.

Conclusions: Evidence was found for the rise of TDR over time. A specific definition of what constitutes TDR rather than a simple list of mutations is needed.

MAJOR ARTICLE – Treatment Interruption of Highly Active Antiretroviral Therapy in Patients with Nadir CD4 Cell Counts >200 Cells/mm3

Source: The Journal of Infectious Diseases 2005 192:1787-1793

Adrienne R. Toulson,1 Richard Harrigan,1,2 Katherine Heath,1 Benita Yip,1 Zabrina L. Brumme,1 Marianne Harris,1 Robert S. Hogg,1,4 and Julio S. G. Montaner1,3

1BC Centre for Excellence in HIV/AIDS and Departments of 2Pathology and Laboratory Medicine, 3Medicine, and 4Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada

Background. The goal of the present study was to characterize outcome and predictors of outcome of treatment interruption (TI) in highly active antiretroviral therapy (HAART)treated patients.

Methods. A systematic chart/database review was conducted to identify patients with nadir CD4 cell counts >200 cells/mm3 and without acquired immunodeficiency syndromedefining illnesses who underwent a TI. Collected data included duration and reason for TI, demographic characteristics, CD4 cell count, and plasma viral load. Human immunodeficiency virus (HIV) envelope (V3) loop genotyping was performed on plasma HIV RNA. The presence of basic residues at aa 11 and/or 25 (the “11/25” genotype) was a further possible prognostic variable of interest. Cox proportional hazards models were used to assess characteristics associated with time to HAART reinitiation after TI.

Results. A total of 208 of 4461 (4.7%) patients underwent TI. The study group consisted of 197 (94.7%) of 208 participants for whom V3 genotyping was successful. The median CD4 cell count at time of the initiation of TI was 620 cells/mm3. A total of 59 (29.9%) patients reinitiated HAART after a median of 15 months. At the time of the reinitiation of HAART, the median plasma viral load was >100,000 copies/mL, and the median CD4 cell count was 260 cells/mm3. Among the 197 study patients, there were 6 deaths, none of which was attributable to the TI. A total of 81% had plasma viral loads Conclusions. Our study suggests that TI is a viable option for HIV-positive adults with nadir CD4 cell counts >250 cells/mm3. A nadir CD4 cell count of 200250 cells/mm3 and the 11/25 viral genotype were found to be associated with a faster HAART reinitiation.

Potential conflicts of interest: none reported.
Presented in part: Canadian Association for HIV Research, Montreal, Canada, 14 May 2004 (abstract 213).
Financial support: Michael Smith Foundation for Health Research (Career Investigator Award and postdoctoral fellowship to K.H.); Canadian Institutes of Health Research (Investigator Award to R.S.H.).

MAJOR ARTICLE – Interruption of Treatment with Individual Therapeutic Drug Classes in Adults with Multidrug-Resistant HIV-1 Infection

Source: The Journal of Infectious Diseases 2005 192:1537-1544

Steven G. Deeks,1 Rebecca Hoh,1 Torsten B. Neilands,1 Teri Liegler,2 Francesca Aweeka,1 Christos J. Petropoulos,3 Robert M. Grant,1,2 and Jeffrey N. Martin1

1University of California, San Francisco, and San Francisco General Hospital and 2Gladstone Institute of Virology and Immunology, San Francisco, and 3ViroLogic, Inc., South San Francisco, California

Background. Many antiretroviral-treated human immunodeficiency virus (HIV)infected patients experience sustained immunologic and virologic benefit despite the presence of multidrug-resistant HIV. We hypothesized that the use of simplified regimens could maintain treatment benefit while preventing viral evolution and reducing drug-related toxicity and costs.

Methods. We conducted a 48-week nonrandomized study of adults with multidrug-resistant HIV type 1 infection. Subjects interrupted protease inhibitor (PI) (n = 18), reverse-transcriptase inhibitor (RTI) (n = 6), or nonnucleoside RTI (NNRTI) (n = 6) treatment.

Results. At study entry, subjects had a median reduction in HIV RNA levels of 1.2 log10 copies/mL relative to pretreatment levels. Interruption of PI treatment was associated with stable HIV RNA levels (mean change per week, +0.005 log10 copies/mL; P = .36). PI mutations waned and replicative capacity and HIV RNA levels increased after long-term observation. HIV RNA levels also remained stable in subjects interrupting NNRTI treatment. In contrast, all subjects who interrupted RTI treatment exhibited immediate increases in HIV RNA levels, and most exhibited a subsequent loss of the M184V mutation.

Conclusions. These data indicate that nucleoside analogues often exert continued antiviral activity in the setting of drug-resistance mutations and that both nucleoside analogues and PIs can select for drug-resistance mutations that reduce viral fitness. These observations support the evaluation of treatment strategies aimed at maintaining the treatment benefit of therapy while reducing drug exposure.

Presented in part: 10th Conference on Retroviruses and Opportunistic Infections, Boston, MA, 1014 February 2003 (abstract 640).
Potential conflicts of interest: C.J.P. is an employee of Virologic, Inc.
Financial support: National Institute of Allergy and Infectious Diseases (grants AI052745 and AI055273); California AIDS Research Center (grants CC99-SF and ID01-SF-049); University of California, San Francisco/Gladstone Institute of Virology and Immunology Center for AIDS Research (grant P30 MH59037); Center for AIDS Prevention Studies (grant P30 MH62246); General Clinical Research Center at San Francisco General Hospital (grant 5-MO1-RR00083-37). Phenotypic susceptibility testing and replicative capacity testing were performed by ViroLogic, Inc.

Pediatric HIV treatment guidelines from DHHS/IDSA were recently updated

Pediatric HIV Treatment Guidelines Revised

Pediatric HIV treatment guidelines from DHHS/IDSA were recently updated to include information on tipranavir and on new formulations of FTC and lopinavir/ritonavir.

The full text of the guidelines is available at
http://aidsinfo.nih.gov/ContentFiles/PediatricGuidelines.pdf.