Living with HIV is a constant challenge, and providers caring for patients with the disease play a key role in helping their patients meet that challenge. The current guidelines from the US Department of Health and Human Services (DHHS) state, “Patients initiating ART [antiretroviral therapy] should be willing and able to commit to lifelong treatment and should understand the benefits and risks of therapy and the importance of adherence.”¹

This commitment is significant, especially given the psychological and socioeconomic difficulties facing many patients who live with HIV. “A lot of people may lose social support once they get diagnosed as a result of the continuing social stigma associated with an HIV diagnosis,” said Leonard Sowah, MB, ChB, MPH, assistant professor of medicine in the Institute of Human Virology at the University of Maryland School of Medicine in Baltimore. “That makes it so important for the provider to have a relationship that may go beyond what we consider normal patient relationships. Without that relationship, a lot of patients may have difficulties with engaging in care.”

Although the treatments for HIV have improved significantly over the past few years, many people living with the disease still are not receiving ART and are not engaged in care.² One study found up to 40% of newly diagnosed patients who were given passive referrals had not initiated HIV care within 6 months of their diagnosis. Alternatively, 78% of patients who received case management and help finding HIV clinics were in care 6 months after diagnosis.³

“As providers, we have to be able to build trust with [patients], involve them in decisions about their health care, and be really clear about what we expect them to do,” said Mary Catherine Beach, MD, associate professor in the Division of General Internal Medicine and core faculty at the Berman Institute of Bioethics and the Welch Center for Prevention, Epidemiology, and Clinical Research at Johns Hopkins University in Baltimore. She pointed out that patients with HIV may need to make lifestyle changes, such as safer sexual practices and changes in substance use habits, as well as medication adherence.

“The relationship between patients and their providers is a particularly important factor in HIV care because the illness is a stigmatized and serious chronic illness,” said Dr. Beach.

Patient-centered care, which is defined as understanding each patient as a unique person, is the standard for high-quality care.^4,5 “From my experience, the patients who really form a relationship with their provider do much better, and they tend to get a lot more engaged in their care,” said Dr. Sowah. “It doesn’t have to be the physician in the team. It can be the case manager, medical assistant, or nurse. There are times when the team leader has to step back and allow the person who has the better relationship with the patient to lead.”

Patient-centered care has a tangible effect on medical outcomes for people living with HIV. Patients who feel that they are seen and appreciated as individuals are more likely to be fully engaged with receiving and adhering to highly active ART, and are more likely to show undetectable levels of serum HIV RNA.⁵ It has been shown that one of the most important issues in patient–provider communication is how open providers are to listening to and learning from their patients.⁶ “Doctors need to be skilled in getting patients to express their opinions and preferences,” said Dr. Beach. “The provider has to understand how the patient views [his or her] illness and be able to negotiate a treatment plan based on that particular patient’s goals and beliefs.”

There are some barriers to creating a good patient–provider relationship, both systemic and personal (Table). “Barrier No. 1 is the reimbursement system,” said Dr. Sowah. He stressed the importance of a strong support system, with social workers, physician assistants, and other team members. He points out that, in the current system, unless a center has Ryan White Comprehensive AIDS Resources Emergency Act funding, it may be difficult to make sure that all these services are fully reimbursed by insurance.

Racial and ethnic disparity between providers and patients also may be a barrier to mutual trust.⁷ Dr. Beach pointed out that, in many areas, HIV predominantly affects racial and sexual minorities.¹ “Because minorities are under-represented in medicine,” she said, “there’s often racial and ethnic discordance between patients and providers. Cross-cultural communication can be challenging.”

Also, Dr. Beach said, “Many providers are very well intentioned, but not necessarily trained in communication techniques.” Fortunately, both cultural disparity and lack of communication skills can be addressed with similar tools. “I think that really understanding where someone is coming from is a critical first step,” she said.

Motivational interviewing, for example, which engages the patient in finding his or her own motivation for behavior change, is the standard of care for risk reduction, according to the Centers for Disease Control and Prevention.⁸ Luckily, said Dr. Beach, “These are skills that people can learn, and it’s not rocket science.”

Finally, said Dr. Sowah, “I think that, as human beings, we don’t only live for ourselves. So for some patients, providing them with something outside of themselves to live for helps them to engage better.”

References

 
1. DHHS. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: initiating antiretroviral therapy in treatment-naive patients (updated October 14, 2011). http://www.aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/10/initiating-antiretroviral-therapy-in-treatment-naive-patients Accessed March 21, 2012.
   
2. Mutchler MG, Wagner G, Cowgill BO, McKay T, Risley B, Bogart LM. Improving HIV/AIDS care through treatment advocacy: going beyond client education to empowerment by facilitating client-provider relationships. AIDS Care. 2011;23(1):79-90.
   
3. Gardner LI, Metsch LR, Anderson-Mahoney P, et al. Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS. 2005;19(4):423-431.
   
4. Balint E. The possibilities of patient-centered medicine. J Roy Coll Gen Pract. 1969;17(82):269-276.
   
5. Beach MC, Keruly J, Moore RD. Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? J Gen Intern Med. 2006;21(6):661-665.
   
6. Apollo A, Golub SA, Wainberg ML, Indyk D. Patient-provider relationships, HIV, and adherence: requisites for a partnership. Soc Work Health Care. 2006;42(3-4):209-224.
   
7. Saha S, Sanders DS, Korthuis PT, et al. The role of cultural distance between patient and provider in explaining racial/ethnic disparities in HIV care. Patient Educ Couns. 2011;85(3):e278-284.
   
8. CDC. Motivational interviewing-based HIV risk reduction. http://www.cdc.gov/hiv/topics/research/prs/resources/factsheets/mihrr.htm. Accessed March 21, 2012.