Low Volume Prescribers of ART Typically Have Less Success in Suppressing Viral Load

Internal medicine was the most commonly reported area of practice by LVPs (41%) followed by family medicine (31%) and infectious diseases (7%).

Patients with HIV who visited clinicians who are typically “low-volume prescribers of antiretrovirals,” identified as clinicians who prescribe for 20 or fewer individual patients, typically have lower quality care and less viral suppression than patients who go to more experienced providers, according to a study published in Clinical Infectious Diseases.

Bruce D Agins, MD, MPH, and colleagues contacted 1,278 low volume prescribers (LVPs) obtained through the New York State Medicaid and AIDS Drug Assistance Program database to find out how ART was prescribed in 2009. In addition, researchers reviewed the patient records of 84 LVPs. All data was compared with high volume providers for viral suppression, clinical visits and identification of co-morbidities.

A total of 368 LVPs were used in the study, who each treated 2-19 HIV patients.The remaining 910 LVPs reported other reasons for giving ART. The researchers interviewed clinicians about area of specialty, compared self-reports of caseloads with the database, gathered reasons why clinicians prescribed ART and about HIV patients who would not appear in the database, such as those who were uninsured, or had Medicare, private or Veteran’s insurance.

While the study researchers noted many patients living outside New York City were more likely to receive care from LVPs. Internal medicine was the most commonly reported area of practice by LVPs (41%) followed by family medicine (31%) and infectious diseases (7%). Only 4 providers said they were HIV specialists.

According to the study, reasons for prescribing ART included “covering gaps in care (45%), providing inpatient care (20%), and use of ART for hepatitis B treatment (13%) or for post-exposure prophylaxis (8%).”

Experienced providers checked viral load more frequently than their LVP counterparts and had higher success in viral suppression, according to the study (56% vs 77%; P < .01). Patients of LVPs weren’t as likely to have regular clinical visits, CD4 cell counts, or be screened for syphilis. They also weren’t as likely to receive mental health screenings according to researchers.

The study was limited because it did not examine length of clinician experience in the treatment of HIV and its effect on care quality, the researchers said. They acknowledged that they also didn’t examine the effect of continuing medical education on clinicians, and that quality of care may reflect patient characteristics Researchers also noted that respondents who gave charts for review may have given better care than those who did not send them, which may indicate performance of LVPs is lower than what researchers found.


1. O’Neil M, Karelas GD, Feller DJ et al. The HIV workforce in New York State: does patient volume correlate with quality? Clin Infect Dis. 2015;61(12):1871–1877.