UCSF study points to new dilemmas confronting HIV healthcare providers

September 06, 2000

The new optimism expressed by healthcare providers treating HIV seropositive patients is mitigated by concerns surrounding treatment decisions and skepticism about the future according to a new University of California, San Francisco study.

"This study focuses a lens on the fact that while combination antiretroviral therapy has provided new hope and joy now that patients are doing better, the treatments are in many ways a mixed blessing. Clinicians expressed worry and fear about what might be around the corner," said the study's lead author, Barbara Gerbert, PhD, professor and chair, Dental Public Health and Hygiene, Division of Behavioral Sciences, UCSF School of Dentistry.

The study, titled "Combination Antiretroviral Therapy: Healthcare Providers Confront Emerging Dilemmas," was published in the August 2000 issue of AIDS CARE.

The study concluded that HIV clinicians were hopeful and excited about their increasing ability to help patients. "Some of the participants have been seeing patients since the beginning of the epidemic and described their work before as 'holding their hands' and 'helping them have a good death.' Now, seeing the effects of combination therapy, their role has changed to helping their patients live," Gerbert noted.

The study also found, however, that this new hope was tempered by skepticism about the future and by their daily struggles to make treatment decisions under conditions of great uncertainty. Gerbert observed, "One doctor said 'I'm sort of besieged by the capacity to do harm. I'm acutely aware of the fact that I can mess up in a fairly significant way by either not prescribing the right thing, forgetting about an interaction, not chasing down the toxicities... This month what I do when I initiate therapy is different from what I did three months ago which is different from a week before that.' Within the studies focus groups, not only did participants voice concerns such as these, but there was not agreement among participants about some issues. The lack of definitive answers highlights the difficulties faced by HIV healthcare providers."

In addition, the UCSF researchers suggested that providers might need access to additional support or a multidisciplinary team to assess and enhance optimally patient adherence to antiretroviral medication regimens.

The major themes that came out of the data collected in the study are:

* Combination therapy has positively changed patients' lives and altered treatment goals.

* The main factors affecting providers' decisions about when to start combination therapy were the risks versus the benefits of delaying therapy, patients' health status, the readiness to adhere and treatment preferences.

* Providers lacked resources to prepare patients to begin therapy and enhance adherence.

* Providers varied regarding assessment of adherence.

* Providers were anxious about making decisions under conditions of uncertainty and were concerned about patient health outcomes.

The data reported in the study was collected using eight focus groups. Twenty-three physicians, eight nurse practitioners and four physician assistants with significant experience providing care to HIV seropositive patients in the San Francisco Bay Area participated in the study. The focus groups ranged in size from three to eight persons and were facilitated by two members of the research team using a structured discussion guide. The same questions were asked in the same order for each group and addressed the following areas: (1) how combination therapy has changed providers' work with their patients (2) how providers deal with patient adherence (3) factors affecting when and to whom providers prescribe combination therapy.
Co-authors of the study are Amy Bronstone, PhD, Division of Behavioral Sciences, UCSF School of Dentistry; Kathleen Clanon, MD, Division of HIV Services, Alameda Medical Center, Highland Hospital, Oakland; Priscilla Abercrombie, PhD, Department of Family Health Care Nursing, UCSF School of Nursing; and David Bangsberg, MD, MPH, UCSF assistant professor of medicine, director of the Epidemiology and Prevention Interventions (EPI) Center at San Francisco General Hospital Medical Center.

University of California - San Francisco

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