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Proxy Measures and Human Immunodeficiency Virus Care
Since 1992, I have provided care for 10 to 20 patients with human immunodeficiency virus (HIV), and have overseen the care of approximately 50 patients in a family practice residency program. My residency was in Galveston, Tex, at a time when the third-largest HIV population in the United States was in Houston, about a 45-minute drive away. My training and experience in treating these patients would qualify me to be considered an "experienced" provider of HIV care.
After reading the article by Willard et al,1 I reviewed my practice records corresponding with the time period studied. I had been practicing in southwestern Missouri, using a standard of care determined by the infectious disease consultant of a tertiary medical center. Standard of care was determined by availability of medication and laboratory testing. Information was available for 8 of my patients. Although viral load testing had been available, it did not become part of our standard of care until the fall of 1996. Similarly, the use of protease inhibitors did not become the standard of care until that time as well. When these patients came to the clinic, I discussed with them the new options in care. If I had participated in the study and been interviewed in November 1996, I might have scored low. If I had been interviewed toward the end of the study in February 1997, I might have scored higher. The article does not state whether physicians provided obstetrical care. Unfamiliarity with vertical HIV transmission prophylaxis may be due in part to a physician's provision of prenatal and/or obstetrical care.
Using the main outcome measures in the article, I would consider myself experienced in treating patients with HIV, but not routinely using protease inhibitors and viral load testing, based on practice location, standard of care, and availability of medication and laboratory testing for the time period of the study. The proxy measures used by Willard et al1 do not capture important factors influencing my clinical practice, and thus emphasize the need to develop a more complete model of factors affecting a physician's practice.
Carin E. Reust, MD
Center for Family Medicine Science
University of Missouri–Columbia
Department of Family and Community Medicine
MA303 Health Sciences Center
Columbia, MO 65212
1. Willard CL, Liljestrand P, Goldschmidt RH, Grumbach K. Is experience with human immunodeficiency virus disease related to clinical practice? a survey of rural primary care physicians. Arch Fam Med. 1999;8:502-508.
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Arch Fam Med. 2000;9:790.
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