Original Research

A shift in referral patterns for HIV/AIDS patients

Philip O. Fournier, MD
Judith A. Savageau, MPH
Robert A. Baldor, MD
University of Massachusetts Medical School, Worcester

The authors reported no potential conflict of interest relevant to this article.

This follow-up study shows that FPs are more likely to make quick referrals of HIV/AIDS patients than a decade ago.


Practice recommendations

  • Funding for specific training programs on HIV/AIDS care should be targeted to community health centers, where there is sufficient volume of HIV patients and an already demonstrated expertise amongst clinical faculty.


Purpose With the rapid development (and complex prescribing patterns) of drugs for HIV/AIDS care, it is challenging for physicians to keep current. We conducted a follow-up study to a 1994 cohort study to see how care and referral patterns have changed over the last decade. In this study, we examined how family physicians in Massachusetts were caring for their HIV-infected patients, and explored whether FPs were referring more patients to specialists for care compared with a decade ago.

Methods We designed a cross-sectional survey as an 11-year follow-up to a previous study. It was mailed in 2005 to the active membership of the Massachusetts academy of Family Physicians.

Results Compared with the cohort of 1994, the number of HIV+ patients in individual practices remained about the same, but the number of practices with no AIDS patients was significantly higher. 85.3% of FPs noted that they were more likely to refer HIV/AIDS patients immediately compared with their own practice patterns a decade ago. In this study, 39.0% of current respondents referred HIV+ patients immediately, 57.0% co-managed patients, and 4.1% managed these patients alone (the data for the 1994 cohort was 7.0%, 45.8%, and 47.2%, respectively; P<.0001).

Similar changes were seen in regard to care patterns for AIDS patients. among the current cohort, 61.7% reported that they referred patients immediately, compared with only 18.3% in 1994; 36.8% noted that they co-managed these patients (vs 74.3% in 1994); and only 1.5% reported that they managed these patients alone (vs 7.4% in 1994; P<.0001).

Conclusions A significant shift amongst FPs with regard to their referral patterns for patients with HIV/AIDS has occurred over the last decade. The community health center has emerged as a resource for patients with HIV/AIDS. Funding for specific training programs on HIV/AIDS care should be targeted to community health centers.

In June 2008, it will be 27 years since the first reported clusters of Pneumocystis pneumonia cases, which were the earliest published reports of the HIV epidemic.1 There are now more than a million individuals infected with HIV in the United States.2

Since the first antiretroviral drug, azidothymidine (AZT), was approved in 1987, more than a dozen medications have been introduced to treat this illness.2 Care for patients with HIV/AIDS is rapidly evolving—so much so that the International AIDS Society publishes revised treatment guidelines every 2 years.3 The US Department of Health and Human Services also issues frequent guidelines for HIV care.4


Asking FPs about their HIV/AIDS management practices

This cross-sectional survey was designed as an 11-year follow-up to a previous research study, described in greater detail elsewhere.12

In June 2005, we obtained a membership listing from the Massachusetts Academy of Family Physicians (MAFP). Using the total design methodology described by Dillman,13 a cover letter and survey instrument were mailed to current MAFP members (N=777). Nonresponders were sent a reminder postcard 2 weeks later, and a second survey 2 weeks after that. A final reminder and survey were mailed to the remaining nonrespondents a month later. No incentives were offered for the completion of the survey.

The survey instrument was developed using the original data collection tool from 1994, supplemented by questions assessing any changes in patient management over the previous 11 years. The 31-item survey included questions about the sociodemographic and practice characteristics of the respondents, their patient mix, their education, and their management of patients with HIV/AIDS, as well as a series of Likert-type attitudinal questions assessing their knowledge, access to specialists, and safety concerns regarding HIV.

Outcomes measured: Changes in care and referral patterns

The main outcomes of the survey were changes in the management of patients with HIV/AIDS, particularly regarding referral patterns compared with the previous decade. Univariate and bivariate statistics, frequency and percentile distributions, as well as means and medians, were used to characterize the physician cohort, their practice characteristics, referral patterns, and attitudes. We also examined a variety of relationships (eg, differences by gender, years of practice, and involvement in teaching), including changes from the data we collected in 1994 (using a repeated cross-sectional design approach).

Data were analyzed using SPSS for Windows, version 14 (SPSS, Inc, Chicago, Ill). Depending on the categorical or continuous nature of the data, chi-square and t-tests were used to assess significance at the .05 level. These bivariate analyses were subsequently used to select which independent variables we would include in the stepwise logistic regression analyses.