Lead/Presenter: Julie Schexnayder, COIN - Durham
All Authors: Schexnayder JK (Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System; University of Alabama at Birmingham), Shehan K (JSI Research and Training Institute, Inc., Boston) Perry K (Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System) Majette Elliott N (Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System) Subramanian S (VA Northeast Ohio Health Care System) Strawbridge E (Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System) Bosworth HB (Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System; Duke University) Gierisch JM (Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System; Duke University)
Cardiovascular disease (CVD) is a leading cause of death among people living with HIV. Hypertension and hyperlipidemia are two highly prevalent CVD risk factors that occur commonly with HIV infection and are often sub-optimally managed. We sought to identify reasons for sub-optimal hypertension and lipids control from the perspectives of Veterans with HIV and their medical care teams.
We conducted in-depth qualitative interviews with Veterans and clinicians at 3 VA HIV clinics (Baltimore, Cleveland, Durham). Interviews followed a semi-structured interview guide that was informed by Self-Regulatory Theory (SRT) and the Information-Motivation-Behavioral Skills (IMB) Model and were conducted by interviewer-notetaker dyads. We used summary templates with real-time member checking and structured debriefings to collect data. We analyzed data using rapid analysis procedures, combining summary template and matrix analyses with team-based coding and weekly consensus discussions. Veteran and clinician data were analyzed separately. We considered the convergence/divergence of resulting themes from these two groups.
A total of 35 individuals participated in in-depth interviews, including 18 Veterans, 10 physicians, 5 nurse practitioners, 1 registered nurse, and 1 pharmacist. Veteran and clinician participants were evenly distributed across the 3 VA sites. Themes aligned with major constructs from the IMB model and SRT. We identified 8 themes that were specific to the Veterans living with HIV: family history and past CVD-related health events as evidence of CVD risk, gaps in CVD-related knowledge, HIV and CVD as separate (and not competing) priorities, self-motivation for sustaining health, confidence in self-managing CVD risk, trust in the HIV care team, lifestyle modifications as a preferred first-line approach to managing CVD, and importance of structure and routines in sustaining health behaviors. Three additional themes were present only in the clinician dataset: moving quickly to medication, confidence in managing CVD risk in teams, and drawbacks of telehealth-based care. Veteran and clinician convergence was observed for three themes: differences in health priorities during medical visits, low awareness of the HIV-CVD risk connection, and COVID impacts on HIV medical visits. COVID resulted in some disruptions (delayed labs, decreased connection with providers), but overall, care for hypertension and hyperlipidemia remained intact. However, Veterans especially preferred a return to more in-person care.
Despite self-reported confidence in managing hypertension and hyperlipidemia by Veterans, we identified multiple opportunities for improving CVD risk factor management among Veterans with HIV. First, the increased risk of CVD conferred by HIV is underrecognized by Veterans living with HIV and often underemphasized by their medical providers. Second, HIV-related conditions are prioritized during HIV medical visits, and differences in Veteranâ€™s and clinicianâ€™s prioritization of other health conditions may divert attention from hypertension and lipids management. Finally, providing increased support for CVD-related lifestyle modification aligns with Veteran preferences and addresses potential gaps in the services offered by VA HIV care teams who are more ready to move to medication management for hypertension and hyperlipidemia.
Our findings provide an important foundation for developing new approaches to reduce CVD burden among Veterans with HIV.