The mysteries and demands of HIV care: qualitative analyses of HIV specialists' views on their expertise.

To deepen our understanding of the mysteries and demands associated with HIV care and to inform the debate about HIV specialization, we conducted in-depth interviews with a purposive sample of 20 identified HIV specialists in the San Francisco Bay Area. Participants were from several medical specialties and reported a median of 50% of their time spent in HIV patient care. Through constant comparison, a template of open codes was constructed to identify themes that emerged from the data. Data were analyzed according to the conventions of qualitative research and revealed six interrelated themes: (1) coping with uncertainty and rapid change: being 'comfortable with mystery'; (2) the powerful role of experience; (3) the dual faces of knowledge: 'knowing the patient' and 'knowing the facts'; (4) the dual faces of passion: challenge and calling; (5) stress and burnout; and (6) the relationship between academia and 'the trenches'. The themes underscore the dual dimensions of HIV care: providers must interweave the 'half-baked' science about drug therapies, side effects and drug interactions with the psychosocial and lifestyle factors of the patient. They also provide insight into quantitative findings linking greater HIV experience with better patient outcomes and suggest that providers need skills associated with generalist and specialist training, a phenomenon that argues for a 'special' specialty for HIV care.

Combination antiretroviral therapy: health care providers confront emerging dilemmas.

Recent editorials, conferences and clinical practice articles have discussed providers' concerns and practices regarding prescribing antiretroviral combination therapy for HIV. We aimed to deepen our understanding of these largely anecdotal reports and of the challenges facing experienced HIV clinicians today using qualitative methodology. Eight focus groups using a structured discussion guide were conducted. Data were analyzed by constant comparative analysis and open codes. Participants were a diverse group of 23 physicians, eight nurse practitioners and four physician assistants with significant experience providing care to HIV-seropositive patients in various San Francisco Bay Area health care settings. The following major themes emerged from the data: (1) providers expressed new optimism about helping HIV-seropositive patients live; (2) the main factors affecting providers' decisions about when to start combination therapy were the risks versus benefits of delaying therapy, and patients' health status, readiness to adhere and treatment preferences; (3) providers lacked resources to prepare patients to begin therapy and enhance adherence; (4) providers varied regarding assessment of adherence; and (5) providers were anxious about making decisions under conditions of uncertainty and were concerned about patient health outcomes. We concluded that experienced HIV clinicians were hopeful and excited about their increasing ability to help patients. This hope, however, was tempered by scepticism about the future and by their daily struggles to make treatment decisions under conditions of great uncertainty. Without access to adjunct supports or a multidisciplinary team, providers may not be able to optimally assess and enhance antiretroviral medication adherence.

How to make the most of your doctor visits.

AIDS: This article describes how patients can take control of a visit to the doctor to ensure their needs are met and questions answered. The author suggests selecting a medical provider that will listen and is appropriate for the level of care required. Nurse practitioners, physicians' assistants and doctors have different abilities to meet medical and personal needs. To benefit from medical visits it is suggested that patients have a clear agenda, and communicate this early to the provider. The patient should also list questions that need to be asked, and be specific about symptoms. Bringing an advocate along who can help ask questions, and remember advice is also useful. Finally the patient should give the provider any additional information acquired.^ieng