Patients of non-specialist HIV physicians often have poor ART outcomes and frequently receive sub-optimal care

Physician experience is associated with the quality of care provided to HIV-positive patients, new research suggests. Investigators in New York State found that the patients of doctors treating fewer than 20 HIV-positive outpatients per year had sub-optimal antiretroviral treatment (ART) outcomes, and also received poor quality of care. The study is published in the online edition of Clinical Infectious Diseases.

“We found that the majority of LVPs [low volume providers] practiced in primary care settings and were not infectious diseases specialists or identified as HIV specialists,” comment the authors.

In the United States, physicians providing care to 20 or more HIV-positive outpatients in a year are classified as HIV specialists. HIV medicine is fast moving. Because of the pace of change in HIV prescribing and care guidelines, investigators in New York State wanted to see if HIV-positive outpatients who received their care from a doctor who prescribed ART to fewer than 20 individuals a year had sub-optimal therapeutic outcomes. The quality of patient clinical monitoring was also assessed.


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The hepatitis B virus can be spread through sexual contact, sharing of contaminated needles and syringes, needlestick injuries and during childbirth. Hepatitis B infection may be either short-lived and rapidly cleared in less than six months by the immune system (acute infection) or lifelong (chronic). The infection can lead to serious illnesses such as cirrhosis and liver cancer. A vaccine is available to prevent the infection.


Affecting the lungs.



The presence of one or more additional health conditions at the same time as a primary condition (such as HIV).


In the United States, a programme providing health insurance to people on low-incomes of all ages. Provision varies from state to state, although some types of care are covered in all states.


A sexually transmitted infection caused by the bacterium Treponema pallidum. Transmission can occur by direct contact with a syphilis sore during vaginal, anal, or oral sex. Sores may be found around the penis, vagina, or anus, or in the rectum, on the lips, or in the mouth, but syphilis is often asymptomatic. It can spread from an infected mother to her unborn baby.

The New York State Medicaid and AIDS Drug Assistance Program databases for 2009 were interrogated to identify physicians who prescribed ART to fewer than 20 patients. These providers were asked to provide details of their caseload and medical specialism.

Physician performance was evaluated against national guidelines. Outcomes were virological suppression, frequency of clinical monitoring and screening for co-morbidities. The investigators compared the performance of low volume providers against those expected of more experienced HIV physicians.

A total of 368 low volume providers were identified. Their annual ART outpatient caseload ranged between 2-19 patients (mean 4.3). The most common physician specialities were internal medicine (41%), family medicine (31%) and infectious diseases (7%).

Additional practice details were provided by 209 (57%) doctors. Twenty-seven reported that they were involved in the co-management of ART-treated patients and 51 said they prescribed ART for reasons other than HIV – for instance the management of hepatitis B virus infection. Only four physicians identified as HIV specialists. However, others said they specialised in the care of HIV-positive women, pulmonary manifestations of HIV infection, or patients recently diagnosed with HIV.

Almost three-quarters of providers were located in New York City. Despite this, patients living outside New York City were more likely to be cared for by low volume providers (OR = 1.7; 95% CI, 1.4-1.9).

Viral load suppression rates were lower among the patients of low volume providers compared to the patients of more experienced doctors (56% vs. 77%, p < 0.01). The patients of low volume providers were also less likely to have regular viral load (44% vs. 90%) and CD4 monitoring (21% vs. 90%). They also had low rates of regular screening for syphilis (32% vs. 80%) and mental health problems (28% vs. 48%).

“Our study highlights the need to monitor data and trends in the HIV workforce,” conclude the authors. “Ongoing research is needed to examine strategies to guarantee a capable provider workforce for delivering effective care to HIV-positive patients over time and identify best practices.”


O’Neil M et al. The HIV workforce in New York State: does patient volume correlate with quality? Clin Infect Dis, online edition. DOI: 10.1093/cid/civ/719.