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VA researcher seeks to improve HIV care for Vets in rural areas

December 13, 2016

Dr. Michael Ohl

Dr. Michael Ohl

Only a modest percentage of the 26,000 Veterans in care for HIV in the United States live in rural areas and have limited access to high-quality HIV specialty clinics.

At the same time, HIV is a chronic condition that can have serious outcomes for patients who lack access to good treatment. The illness attacks the body's immune system and can cause AIDS, a potentially life-threatening disease. Long-term coordinated care by both a primary physician and an HIV specialist is essential.

Dr. Michael Ohl, an infectious disease specialist and HIV clinician with the Iowa City VA Health Care System, recognizes this challenge. The recipient of a Career Development award through VA's Health Services Research and Development program, he's seeking to create a model that will improve the accessibility and quality of specialty care for rural Veterans with HIV.

For his research, the "rural" classification is based on population density and proximity to VA specialty clinics in urban areas. Most of the rural Vets with HIV are men who contracted the illness through sex with other men, or in some cases through sharing intravenous needles. Women have gotten it through heterosexual contact and sharing needles.

HIV care for rural Veterans

HIV care for rural Veterans

Ohl says rural Vets with HIV are less likely to have an HIV test early in their illness.

"That means rural people with HIV are diagnosed with HIV infection and linked to care at a more advanced stage of infection. They have more severe immune compromise or are more likely to be sick or to have AIDS at the time that they are diagnosed in care. HIV infection is generally asymptomatic for a period of several years, but in the absence of treatment people develop AIDS and become seriously ill."

Providing HIV care through videoconferencing

Currently, Ohl is studying a telehealth model aimed at providing accessible and comprehensive specialty care for rural Vets with HIV. Telehealth means delivering care or services from a distance—for example, through videoconferencing.

"If we can figure this out for HIV, it can have implications for other conditions."

Ohl calls the model Telehealth Collaborative Care (TCC). The main goal of his study is to learn whether Vets who live near one of VA's community-based outpatient clinics (CBOCs)—small primary care sites that serve as satellite clinics for large VA campuses—welcome the chance to telecommunicate with an HIV specialist as a way to maintain their ongoing relationship.

The Veteran wouldn't have to travel long distances to an HIV specialty clinic, which are usually in large VA hospitals in cities. An HIV pharmacist, psychologist, or nurse-care manager may also be in on the video conference. A nurse at the outpatient clinic can administer treatment if it is prescribed by the specialist.

A Veteran can also meet with his or her primary care physician on-site. The primary care clinic and specialty care clinic can communicate, as well, to figure out how to best co-manage the patient.

The coordinated process lifts a major travel burden on Vets. Ohl has noted in his research that in 2010, rural Vets with HIV were 86 minutes by car from the closest infectious disease clinic, versus 23 minutes for urban Veterans. The rural Vets also were somewhat less likely than their urban counterparts to use specialty care.

The TCC study, which involves about 800 Veterans, is focusing on rural areas near San Antonio, Houston, Dallas, and Atlanta, each of which has a VA hospital with a specialty HIV clinic. Veterans with HIV who live closer to a primary care clinic, or a CBOC, than to a specialty clinic and may have at least a 90-minute drive to the city are being offered telehealth.

Ohl says that through interviews with the Vets, he and his team are finding that most of those offered telehealth are choosing to take advantage of the option.

Results from the study are expected in the next year or two.

The research builds on Ohl's 2013 TCC pilot study, which found that 94 percent of rural Veterans with HIV (30 of 32) chose telehealth over traveling to the HIV clinic at the VA hospital in Iowa City. The study, which included patients from rural Iowa and Illinois, also showed that the average yearly travel time fell from 320 minutes before the study, when patients would be driving to the HIV clinic in Iowa City, to 170 minutes during the study, when they were driving to their nearest CBOC.

Nearly all of the patients were men, with an average age of 54.

Vets with HIV prefer direct contact with specialist

Ohl turned to the telehealth model after one of his other studies, published in August 2016 in the Journal of Rural Health, examined a program that calls for rural Vets with HIV to see a primary care doctor at a rural outpatient clinic. The doctor would in turn communicate with remote HIV specialists to guide management.

But this form of the Specialty Care Access Network—Extension for Community Health Outcomes (SCAN-ECHO) model, which has been successfully applied to hepatitis C patients, had little success when tested at two large metropolitan VAs on the West Coast and one small VA in the Midwest.


Only 9 of 21 rural primary care clinics (43 percent) adopted the HIV SCAN-ECHO model, and only 47 of 776 eligible Veterans (6 percent) participated. Instead, patients preferred to continue driving to the distant HIV specialty clinic, often bypassing more nearby primary care clinics on the way.

Those results were largely attributed to a reluctance by patients to transfer their HIV care from specialty clinics to primary care facilities, and to HIV "exceptionalism," a sense on the part of many patients and providers that HIV care is clinically and culturally unique and should not be integrated into the wider primary care system. Vets opted to drive long distances because of a comfort level they felt with their regular HIV doctors at specialty clinics, Ohl says.

"There was this idea that HIV care is so technically complex and culturally different that it shouldn't be happening in primary care clinics, it should be happening in specialty clinics. Therefore, even though you live hours away and nearer to a primary care clinic, HIV care is so exceptional that you're willing to drive hours to the specialty clinic.

Ohl continues: "Given that experience, we pivoted and asked Veterans, `What if you go to your local outpatient clinic and establish care with a primary care provider but also continue to see the entire specialty team by video in an HIV specialty clinic as needed? Then you can have access to both a local primary care person and a specialist, and they can coordinate their care.' They said yes, and that's where we got the 30 of 32" in the TCC pilot study.

Ohl says the issue of rural HIV care may be a paradigm for other conditions where a Veteran visiting a CBOC can see a primary care doctor and telecommunicate with a specialist in a distant city-based clinic.

"If we can figure this out for HIV, it can have implications for other conditions."

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