Many HIV-positive people who are taking potent combination therapy for HIV (commonly called ART or HAART) and who do not have co-existing conditions are generally otherwise healthy. They may therefore need to see a doctor less frequently. Doctors at a major clinic in Brighton, UK, have found that the number of HIV-positive patients in their care has been increasing by 5% to 7% per year for the past 10 years. However, staffing has not increased in proportion to the growth in the patient population at the Brighton clinic.

In general, patients at their clinic fit this profile:

• 88% are taking ART
• 95% of ART users have a viral load less than 50 copies/ml
• 68% get home delivery of their medicines

The standard of care at the Brighton and Sussex University hospital clinic is to have an HIV specialist see medically stable HIV-positive patients every four months. Two weeks prior to each of these clinic visits, patients go to a lab to have their blood drawn and analysed.

In 2008 the Brighton clinic established an email service for patients with the following profile:

• have been under the care of a clinic physician for more than one year
• have stable viral load test results (at least two consecutive test results less than 40 copies/ml) or more than 350 CD4+ cells
• have no other health conditions
• have Internet access
• have a family physician

Prospective patients were told about the service and had to sign a consent form to become enrolled. Under the new system, routine visits to an HIV specialist were limited to once a year.

Out of the several thousand patients at the clinic, initially 33% (674) signed up for the email service and reduced visits. The average profile of participants who enrolled was as follows:

• 91% men, 9% women
• 88% were white
• 83% were men who have sex with men (MSM)
• participants ranged in age from 21 to 81 years with the mid-point being 47 years
• all had stable HIV infection with 93% on ART and 97% of ART users had a viral load less than 40 copies/ml
• diagnosed with HIV for 11 years

However, eventually 33 participants chose to leave the email service for these reasons:

• preferred to be seen every six months – 10 patients
• missed more frequent visits to the doctor – 7 patients
• moved out of the area – 2 patients
• problems with home delivery of medicines – 2 patients
• computer problems – 2 patients
• other, unspecified reasons – 10 patients

Temporary stops

At present, 117 patients have temporarily stopped using the new system because of the need for more intensive medical care, such as the following:

• medical issues (including HCV co-infection) – 60 patients
• entered research studies – 26 patients
• decided to initiate or change ART – 26 patients
• other reasons – 5 patients

Satisfaction

Overall, 90% of participants rated the service “good” or “excellent.”

Participants particularly like the following aspects of the service:

• fewer hospital clinic visits
• access to blood test results via email
• the ability to go to the lab early (7:30 am) and how it does not interfere with their job

96% of participants would recommend the service to a friend who was HIV positive.

Patients left comments such as these:

• “for busy people the service is excellent”
• “fabulous service, roll it out for the whole country”
• “…modern patient-centred approach to chronic disease management that other services should be copying”

The Brighton researchers have found a way to save money and keep patients satisfied at the same time. Other clinics serving people with HIV and other chronic health conditions may find a similar service useful.

—Sean R. Hosein

REFERENCE:

Whetham J, Hendrikx C, Fisher M. Four years’ experience of an email clinic in an outpatient HIV setting. In: Program and abstracts of the 14th European AIDS Conference, 16-19 October 2013, Brussels, Belgium. Abstract PS8/6.