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

Abstract

Background People with HIV (PWH) experience increased cardiovascular disease (CVD) risk. Many PWH in the USA receive their primary medical care from infectious disease specialists in HIV clinics. HIV care teams may not be fully prepared to provide evidence-based CVD care. We sought to describe local context for HIV clinics participating in an NIH-funded implementation trial and to identify facilitators and barriers to integrated CVD preventive care for PWH. Methods Data were collected in semi-structured interviews and focus groups with PWH and multidisciplinary healthcare providers at three academic medical centers. We used template analysis to identify barriers and facilitators of CVD preventive care in three HIV specialty clinics using the Theoretical Domains Framework (TDF). Results Six focus groups were conducted with 37 PWH. Individual interviews were conducted with 34 healthcare providers and 14 PWH. Major themes were captured in seven TDF domains. Within those themes, we identified nine facilitators and 11 barriers to CVD preventive care. Knowledge gaps contributed to inaccurate CVD risk perceptions and ineffective self-management practices in PWH. Exclusive prioritization of HIV over CVD-related conditions was common in PWH and their providers. HIV care providers assumed inconsistent roles in CVD prevention, including for PWH with primary care providers. HIV providers were knowledgeable of HIV-related CVD risks and co-located health resources were consistently available to support PWH with limited resources in health behavior change. However, infrequent medical visits, perceptions of CVD prevention as a primary care service, and multiple co-location of support programs introduced local challenges to engaging in CVD preventive care. Conclusions Barriers to screening and treatment of cardiovascular conditions are common in HIV care settings and highlight a need for greater primary care integration. Improving long-term cardiovascular outcomes of PWH will likely require multi-level interventions supporting HIV providers to expand their scope of practice, addressing patient preferences for co-located CVD preventive care, changing clinic cultures that focus only on HIV to the exclusion of non-AIDS multimorbidity, and managing constraints associated with multiple services co-location. Trial registration ClinicalTrials.gov, NCT03643705

Perspectives of HIV specialists and cardiologists on the specialty referral process for people living with HIV: a qualitative descriptive study

“…For patients with uncontrolled CVD-related conditions, HIV specialists reported that they first managed the conditions, including titration of CVD medications up to the provider’s level of comfort and confidence after which they would refer their patients to cardiologists mostly for medication management. In previous studies, HIV specialists were found to have low levels of comfort and confidence prescribing CVD-related medications, and the involvement of cardiologists in CVD medication management may be necessary [ 34 , 35 ].…”

Multimorbidity Burden and Incident Heart Failure Among People With and Without HIV: The HIV-HEART Study

“… 42 Managing complex treatment regimens associated with multiple chronic conditions is challenging in the case of PWH, and often care for HIV takes priority. 19 Many chronic comorbidities are also discordant with HIV (ie, not directly related in pathogenesis or management) and care for these conditions can remain suboptimal. 20 , 21 , 43 However, contemporary advances in primary care guidance may help reduce some treatment discordances.…”

“… 17 , 18 Some comorbidities have treatment recommendations that are discordant with HIV care, and in PWH, this can create a difficult choice between managing their HIV and conditions that potentially increase their risk for CVDs. 19 , 20 , 21 Previous studies have examined multimorbidity in people with established CVDs, but there is less research examining the association between multimorbidity and incident CVD. 22 The impact of multimorbidity burden on the risk of incident HF, especially among PWH and PWoH, is largely unknown.…”

Addressing gaps in cardiovascular care for people with HIV: bridging scientific evidence and practice

“…The National Heart, Lung, and Blood Institute has taken note and is now funding five research teams conducting implementation studies to combat chronic comorbidities experienced by those with HIV, many of which are cardiovascular [61]. There are a variety of interventions that include nursing led care coordination for blood pressure and cholesterol management, patient activation strategies for ASCVD risk reduction, and behavioral economics informed feedback for providers through peer comparisons of statin prescription [19,61]. Another study, recognizing the contribution of mental illness to CVD in PLWH, addresses patients' trauma history to increase engagement in care [61].…”

“…Taken together, these factors contribute to elevated CVD risk but also increase barriers to CVD prevention and therapy among PWH. Understanding and addressing these factors in a comprehensive, integrated manner is necessary to achieve progress in CVD prevention and treatment of PWH [19]. Accordingly, this review focuses on these unique areas of CVD risk among PWH, with a particular focus on major gaps and emerging practical targets to reduce CVD risk and morbidity among PWH (Fig.…”