Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes

Abstract

Background.Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics (“consolidated care”) or combining HIV care with comorbidity management in primary care clinics (“shared care”). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care.Methods.We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients’ likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics.Results.Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04–1.68).Conclusions.Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.

How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs

“…The finding might be explained by Relational Coordination Theory, which suggests that routines, such as clinical guidelines and clear designation of responsibility, can improve communication and relationships among teams to maximize performance 15. In prior work, we found that hypertension outcomes were better when provided in HIV clinics, rather than when care was shared by HIV and primary care clinics 25. This may be because of a lack of coordination regarding hypertension care across clinics.…”

“…15 In prior work, we found that hypertension outcomes were better when provided in HIV clinics, rather than when care was shared by HIV and primary care clinics. 25 This may be because of a lack of coordination regarding hypertension care across clinics. As medical centers move toward HIV specialty care, focusing on the transition to primary care management of comorbidities and ensuring consistency may be critical to patients' receiving appropriate care for all their health concerns.…”

Understanding constraints on integrated care for people with HIV and multimorbid cardiovascular conditions: an application of the Theoretical Domains Framework

“…In the USA, there are limited evaluations of HIV clinics that integrate multiple CVD preventive services [ 26 ]. The few examples [ 27 – 29 ] do not address the full cache of conditions needed for comprehensive CVD prevention and present mixed findings when comparing outcomes to shared care or consolidated care models. Additional study is needed to determine how successful integrated care models can be expanded to address all of the CVD prevention needs of PWH [ 24 ].…”

Hypertension among persons living with HIV — Zambia, 2021; A cross-sectional study of a national electronic health record system

“…Some of the existing practices that rely on referring patients with elevated BPs to the outpatient department (i.e., urgent care) for further evaluation might result in patient attrition, missing opportunities to adequately manage this common comorbidity among PLHIV in Zambia. Integrated primary care models for PLHIV have better outcomes for non-communicable disease management (40), and can even result in better viral suppression (41). ART clinics in Zambia might benefit from instituting integrated management of noncommunicable diseases, including life-style modification, anti-hypertensive therapy with appropriate treatment intensification, and medication adherence assessments for hypertension (42).…”