'Virtual Hospital' a satisfactory and safe way to deliver care to clinically stable HIV-positive patients

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A ‘Virtual Hospital’ that provides a comprehensive package of HIV care is a safe and feasible option for chronically HIV-infected people whose condition is stable, a Spanish study published in the online journal PLoS ONE  suggests.

Patients found their online care satisfactory, and outcomes were comparable to those seen in people whose HIV care was provided in the clinic.

“The study shows that Virtual Hospital constitutes a feasible, fairly satisfactory and safe tool for the clinical care of stable HIV-infected patients,” write the authors; “it has no deleterious effect on HIV clinical parameters, antiretroviral compliance, quality of life, or psychological and emotional status.”

Glossary

detectable viral load

When viral load is detectable, this indicates that HIV is replicating in the body. If the person is taking HIV treatment but their viral load is detectable, the treatment is not working properly. There may still be a risk of HIV transmission to sexual partners.

opportunistic infection (OI)

An infection that occurs more frequently or is more severe in people with weakened immune systems, such as people with low CD4 counts, than in people with healthy immune systems. Opportunistic infections common in people with advanced HIV disease include Pneumocystis jiroveci pneumonia; Kaposi sarcoma; cryptosporidiosis; histoplasmosis; other parasitic, viral, and fungal infections; and some types of cancer. 

exclusion criteria

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.

capacity

In discussions of consent for medical treatment, the ability of a person to make a decision for themselves and understand its implications. Young children, people who are unconscious and some people with mental health problems may lack capacity. In the context of health services, the staff and resources that are available for patient care.

prognosis

The prospect of survival and/or recovery from a disease as anticipated from the usual course of that disease or indicated by the characteristics of the patient.

The outlook of many HIV-positive patients has been transformed by antiretroviral therapy. However, the near-normal prognosis of a large number of HIV-positive individuals coupled with a high rate of new infections means that many clinics have to cope with an ever-increasing patient population.

Routine HIV care can also be inconvenient for patients.

Clinically stable patients typically have check-ups every three to four months. These visits usually involve seeing a number of healthcare professionals including a specialist HIV doctor, nurse, phlebotomist and pharmacist. This means a considerable time commitment from both staff and patients.

Investigators in Barcelona, Spain, reasoned that the provision of routine HIV care via the internet was a solution to the capacity, cost, and time issues that are associated with the increase in the HIV-positive population.

A Virtual Hospital was therefore developed which provided comprehensive HIV care via the internet.

Consultations with doctors were provided via video conferencing, and other healthcare professionals were also available via electronic media. Medications were dispatched to the patients’ home address using couriers.

The researchers wished to see if the Virtual Hospital was satisfactory and safe. A study was therefore conducted involving 83 patients. All the patients were clinically stable and had a CD4 cell count above 250 cells/mm3. People taking HIV therapy who had a detectable viral load were excluded from participation, as were those who had cancers or active opportunistic infections.

To be included in the study, patients were required to have a home computer and broadband internet connection. Training, lasting 20 minutes, was provided to users.

The patients were randomised into two groups. Those in the first arm of the study received their care via the Virtual Hospital, and individuals in the second continued to receive traditional clinic-based care. After a year, patients switched study arm and were followed for another twelve months.

Investigators monitored patient satisfaction and clinical outcomes, and also evaluated quality of life and psychological and emotional wellbeing.

Most of the patients (93%) were employed and 38% had a university degree. At  baseline, 55% of patients were taking HIV therapy. The study was completed by 75 patients.

Satisfaction with the Virtual Hospital was high, and 85% of patients considered that it improved their access to clinical data compared to standard care. A similar proportion were comfortable with video conferencing as a way of consulting their HIV doctor. This system was rated as an easy way to communicate by 82% of users.

Overall, 69% of patients were satisfied with the Virtual Hospital.

There was no difference in clinical outcomes between users of the Virtual Hospital and users of routine care. CD4 cell counts were comparable between the two arms of the study, as was the proportion of patients treated with HIV therapy who had an undetectable viral load.

Just over a quarter of patients (28%) switched therapy, and 6% of individuals started HIV treatment for the first time. Rates of switching and starting treatment were comparable between the two study arms.

Adherence rates were high, and did not differ between study arms.

Use of the Virtual Hospital did not have an adverse effect on overall quality of life, or on emotional and psychological wellbeing.

Installing the hardware and software cost the clinic 50,000 euro, and the annual cost of the service for each patient was 120 euros.

The investigators calculated that the average consultation using the Virtual Hospital took ten minutes, compared to the 60 to 90 minutes needed for a visit to the clinic.

“The Virtual Hospital has been shown to be a feasible and safe tool for providing multidisciplinary home care to chronic HIV patients,” comment the investigators, concluding: “telemedicine should be considered an appropriate support service for the entire management of chronic HIV infection, [and] is likely to prove extremely useful in settings with poor access to the health system.”

References

Leon A et al. A new multidisciplinary home care telemedicine system to monitor stable chronic human immunodeficiency virus-infected patients: a randomized study. PLoS ONE, 6 (1):e14515, 2011.