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Decentering HIV Specialty Care

Moeckli J, Ono SS, Dillon D, Ohl M. Decentering HIV Specialty Care. Paper presented at: American Anthropological Association Annual Meeting; 2012 Nov 16; San Francisco, CA.

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With the development of effective antiretroviral therapy, HIV infection has transformed from a progressive and fatal illness into a chronic condition. Thus, optimal care for persons with HIV now includes comprehensive primary and preventative health care. Veterans Affairs (VA) health system is the largest provider of HIV care in the United States with over 23,000 Veterans in care for HIV infection, approximately 18% of whom live in rural areas. In urban areas with higher prevalence of HIV, Veterans receive integrated HIV and primary care using co-located interdisciplinary teams. This model does not adapt to rural areas with lower HIV prevalence that cannot support co-located HIV specialists in local outpatient clinics. To improve access and integrate care for rural Veterans with HIV, a pilot telemedicine program was implemented in a Midwestern catchment area to connect HIV specialists with patients and their primary care providers in rural clinics. Drawing on interviews with providers, nurses, and Veterans, this paper examines the impact of telemedicine on collaboration and coordination between patients, specialists, and primary care providers. Rather than further rigidifying the unequal distribution of resources between the centralized specialty clinic and the rural clinics in its network, this paper argues that telemedicine-enabled care actually decentralizes specialty care, and creates opportunities for generative knowledge to be created between co-located and distant teams and the patients in their care. In this context, telemedicine facilitates the expansion of knowledge about HIV infection and co-morbidity management among providers, and provides a more participatory care model among Veterans. Keywords: HIV, telemedicine, co-managed health care, virtual teamwork, rural Midwestern US.

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