Factors affecting statin uptake among people living with HIV: primary care provider perspectives

Abstract

Background Cardiovascular disease (CVD) is a major cause of morbidity and mortality among people living with HIV (PLWH), but statin therapy, safe and effective for PLWH, is under-prescribed. This study examined clinic leadership and provider perceptions of factors associated with statin prescribing for PLWH receiving care in eight community health clinics across Los Angeles, California. Methods We conducted semi-structured telephone interviews with clinic leadership and providers across community health clinics participating in a larger study (INSPIRE) aimed at improving statin prescribing through education and feedback. Clinics included federally qualified health centers (N = 5), community clinics (N = 1) and county-run ambulatory care clinics (N = 2). Leadership and providers enrolled in INSPIRE (N = 39) were invited to participate in an interview. We used the Consolidated Framework for Implementation Research (CFIR) to structure our interview guide and analysis. We used standard qualitative content analysis methods to identify themes within CFIR categories; we also assessed current CVD risk assessment and statin-prescribing practices. Results Participants were clinic leaders (n = 6), primary care physicians with and without an HIV specialization (N = 6, N = 6, respectively), infectious diseases specialists (N = 12), nurse practitioners, physician assistants and registered nurses (N = 7). Ninety-five percent of providers from INSPIRE participated in an interview. We found that CVD risk assessment for PLWH is standard practice but that there is variation in risk assessment practices and that providers are unsure whether or how to adjust the risk threshold to account for HIV. Time, clinic and patient priorities impede ability to conduct CVD risk assessment with PLWH. Conclusions Providers desire more data and standard practice guidance on prescribing statins for PLWH, including estimates of the effect of HIV on CVD, how to adjust the CVD risk threshold to account for HIV, which statins are best for people on antiretroviral therapy and on shared decision-making around prescribing statins to PLWH. While CVD risk assessment and statin prescribing fits within the mission and workflow of primary care, clinics may need to emphasize CVD risk assessment and statins as priorities in order to improve uptake.

Effect of 2018 American College of Cardiology/American Heart Association Guideline Change on Statin Prescription for People Living with HIV

“…For example, time constraints impede HIV providers from focusing on ASCVD risk assessment and prevention given that care delivery prioritizes HIV management. ( Ober et al, 2021 ) Lack of cardiovascular disease-specific knowledge and uncertainty about drug-drug-interaction between statins and ART are additional reported barriers. ( Ober et al, 2021 ) Barriers to statin prescription among people without HIV may also be relevant to PLWH.…”

“…( Ober et al, 2021 ) Lack of cardiovascular disease-specific knowledge and uncertainty about drug-drug-interaction between statins and ART are additional reported barriers. ( Ober et al, 2021 ) Barriers to statin prescription among people without HIV may also be relevant to PLWH. These barriers include poor patient-provider relationships and concerns about patient adherence, cost, and over-reliance on statins.…”

“…These barriers include poor patient-provider relationships and concerns about patient adherence, cost, and over-reliance on statins. ( Ober et al, 2021 , Butalia et al, Nov 2020 , Kedward and Dakin, 2003 ) A stepped-wedge cluster randomized trial is in progress at Los Angeles community health clinics to intervene in organization-, provider-, and patient-level barriers to statin prescription. ( Takada et al, 2020 ) Results from this trial and related future studies may be useful for identifying promising strategies to implement across settings to increase statin prescription.…”

A Systematic Review of How To Reduce Morbidity in HIV Patients With Cardiovascular Diseases

“…Statins are widely used in the primary and secondary prevention of CVD in the general population. Though they have the potential to prevent CVD in PLWH, they are being underprescribed by clinicians [16,24]. The reasons for this and their usage spread over a wide spectrum, ranging from clinician-level factors, including limited knowledge of prescribing guidelines, all the way to patient-related factors like non-adherence and a lack of knowledge regarding the benefits of statins [16].…”

Implementation of a bundle to improve HIV testing during hospitalization for people who inject drugs

“…This low rate of testing occurred in the wake of persistent HIV outbreaks in the communities our hospital serves (Gonsalves et al, 2021;Hamdan et al, 2022). Although there has been recent improvement of including perspectives of nurses and physicians' assistants in the development of improved care, their voices are often missing (Ober et al, 2021;Wilson et al, 2021;Zhang et al, 2020).…”