Our study shows that it is possible to establish shared care programs with Primary Care in selected PLWH, while maintaining good adherence and virological control, reducing patient journeys, and achieving a good degree of satisfaction.
From the initial questionnaire, it is striking that 108 patients (12%) reported not knowing their GP and that 28% hadn’t been to their PHC during the previous year. To date, in Europe and in many high-income countries, care for patients with HIV infection has been carried out mainly in hospitals, so it comes as no surprise that a percentage of patients are not aware of or do not use PHC (10). We agree with the British HIV association, that recommends that every patient with HIV infection must remain under the care of a suitable specialist service but must also be strongly encouraged to register with a GP (9).
In general, satisfaction with medical care was very good, despite being slightly higher within specialized care. In our center, specialized care has been carried out in the last few years by the same doctors who are experts in infectious diseases-HIV infection and by hospital pharmacists. Meanwhile, in the Primary Care setting, changes of GP and lack of means are not uncommon. What is striking is both the high percentage of patients with comorbidities in a population with a mean age under 50 years and the fact that during the 2-year follow-up of the PPAC, 10% were diagnosed with cardiovascular events or unrelated neoplasms.
If we want to improve the care of PLWH, it is necessary to implement management strategies and organizational models that have demonstrated their effectiveness in other chronic diseases, which includes improving coordination with Primary care (11–12). Patient transfer or share for chronic conditions has received surprisingly little attention from researchers, with some authors suggesting more research is urgently required regarding reasons for and outcomes of transfers, transfer processes, and interventions to optimize transfers for different chronic conditions (13).
Many studies on Primary care of PLWH in developed countries have been carried out in Canada and in the United States, where an attempt has been made to implement the Chronic Care Model (CCM) in some places, observing that it enables significant improvement of certain quality indicators such as vaccination against pneumococcus, screening for syphilis or TB, adherence to ART, and percentage of patients with undetectable VL(14).
Our Pilot Project, which initially consisted of training sessions at the PHC Centers, establishing easy communication channels with the PHC, and later sharing the care of well-controlled selected patients with multiple pathologies, enabled the gradual approach of patients to the Health Centers. We believe it is not only a good way to coordinate the care of these patients but also to improve early diagnosis of HIV infection and other sexually transmitted infections (STIs) in the Primary care setting.
The strength of this observational study is its prospective nature with a follow-up of over two years and pre-established outcome variables. In this model, 72 patients remained in the program (87%), with good adherence and virological control and with a very good acceptance of the program. Nine patients requested exit from the program and one patient was not eligible for follow-up due to relapse in alcohol consumption.
There are very few previous studies carried out in developed countries with the aim of promoting shared care of PLWH. Further, some of them achieved poor recruitment, although this was in situations where HIV infection was still symptomatic in many patients (3). Others such as Page's, in Switzerland, showed no difference either in adherence to ART, or in virological control by level of care, with satisfaction being higher in those seen in Primary Care (9). Other studies evaluating the follow-up of PLWH in PHC have tried to determine the variables related to losses to follow-up (15), and the characteristics of the patients seen and the services offered by providers(16, 17), or attempted to evaluate some interventions to improve depressive symptoms and quality of life, or to understand the chronic nature of HIV(4)(18–19).
In order to improve the acceptance of PLWH being followed in the primary care setting, we must try to overcome some of the barriers that patients describe. One of these is some GPs’ lack of knowledge about HIV infection, the lack of confidentiality in some PHC care such as blood sample extractions, or the saturation of some services. The providers’ linkage-making behaviors will be influenced by their knowledge (HIV- and linkage-related training) and their opinions and attitudes toward Interprofessional collaboration (20). In our country, family residents do not receive proper training on HIV infection or infectious disease, as infectious diseases are not recognized as a specialty. We demonstrate that HIV education programs in Health Centers are feasible. In addition, as a result of this program, some services have been brought closer to patients, such as blood testing and specific HIV tests, which can be done in PHC.
Various studies carried out in the US and Great Britain show that some PLWH may prefer accessing specialist services as it provides anonymity and there still exists some stigma around an HIV test being in medical records (21). This can be especially important and must be taken into account in regional contexts such as our hospital, located on a small island. Finally, the patient’s choice must be respected. Other services for improvement proposed by patients, but not yet available in our environment, would be the ARV approach, and on-line access to their health record and analytical results. These services, as well as the possibility of telephone consultations, tele-assistance, and on-line clinical sessions with PC, have demonstrated their importance in situations such as the current COVID pandemic.
The main limitations of the study are the small number of patients included in the pilot Project (since February 2020, with the COVID pandemic no new patients have been enrolled in the PPAC). This program was carried out in a developed country where access to health care is universally granted and it only included selected patients with good previous follow-up who agreed to enter the program. Therefore, the applicability might not be extrapolated to other countries or settings.
CONCLUSIONS It is possible to establish shared care programs with Primary Care in selected patients with HIV infection, thereby reducing hospital visits, while maintaining good adherence and virological control and achieving high patient satisfaction. To improve the continuity of the program, it is important to better the aspects suggested by the patients: greater knowledge of HIV, less replacement of GPs, and greater confidentiality in blood draws.