UCSF study points to new dilemmas confronting HIV healthcare providers

By Jeff Sheehy

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
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
* 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.