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Professor of Medicine
School of Medicine
Site Leader, Global Infectious Diseases
Clinical Trials Unit
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
David A. Wohl, MD, has disclosed that he has received funds for research support from Gilead Sciences, Merck, and ViiV and consulting fees from Gilead Sciences, Janssen, Merck, and ViiV.
I now know what it is like to be in a long-distance relationship. Instead of looking each other in the eye and touching, we chat by phone or sometimes video chat. I wear headphones, and at some point, we run out of things to say or time and then we hang up. This is the way things are in the time of COVID-19—not with my partner but with my patients with HIV. Surprisingly, this has turned out better than I expected. Mostly, when I call they sound cheerful—hunkered down and very happy to dodge being caught up in another pandemic.
The interim guidance for COVID-19 and persons with HIV, updated in June 2020, continues to suggest telephone or virtual visits for routine or nonurgent care and/or adherence counseling. These remote clinic visits tend to be shorter than the in-person kind, but that may reflect my lifelong dislike of talking by telephone (and don’t get me started on Zoom). We still seem to cover the same ground, just more efficiently, as if we really were calling on a dime. But then there is Raquel. She is one of my most charming and more challenging patients. Congenitally infected, she has travelled that long road like many others who have had to deal with HIV their entire lives, with bumps, breakdowns, and a few ART resistance mutations along the way. More than once, she has told me she does not really like coming to clinic.
Most recently, 27-year-old Raquel has been dealing with caring for her 1- and 4-year-old sons while also working and trying to earn a degree online. Suppression of her viral load has been hit and miss—during her pregnancies she tended to drive her RNA level below detection, but it has been variable in between. Following her last delivery, her viral load drifted up. Eight months before the outbreak, her plasma HIV-1 RNA rebounded to 14,000 copies/mL, and after a missed clinic visit, she reported missing 2-3 doses of her bictegravir/emtricitabine/tenofovir alafenamide each week. She committed to try harder to not miss her medication and to tag dosing with brushing her teeth in the morning, and her viral load fell to 3000 copies/mL. That was right before COVID-19 hit.
Since then, she missed a phone appointment. We quickly rescheduled the call, and she said she had been doing better taking her medications, as she was at home on furlough from her office. I ordered blood work at a local commercial laboratory that she cheerily told me she would go to the next day. She didn’t. I sent her messages via our electronic medical record system but got crickets in return. She had an upcoming video clinic visit with gynecology, and I asked the nurse practitioner in that clinic to remind Raquel to get her blood work done when she did her pre-visit call. Raquel kept that visit, and after prompting from the nurse practitioner, she had her labs done the next day. Go team GYN! I saw the result was final a few days later, and as I clicked on it, I was prepared for a 4-5 digit viral load but saw only the words “Not Detected.” I messaged her the results and got an emoji loaded reply of fireworks, smiley faces, and hearts and assurance that she was actually looking forward to seeing me “IRL.”
It could have been a different story, however, if her viral load had not been suppressed. In that case, it may have been hard keeping our doctor–patient relationship at arm’s length. The NIH interim guidance states that patients and their providers should weigh the risks and benefits of attending, vs not attending, in-person, HIV-related clinical appointments. Having had time to implement precautions to reduce COVID-19 risk, our clinics are getting more accustomed to seeing patients, even for routine visits. Had I the need to see Raquel in-person for some heart-to-heart about her adherence or medication intolerance, we could do that. She would wear a mask, and I would wear a mask and eye protection—what we are calling universal pandemic precautions. I would have certainly done this if I needed to get same-day labs and change her HIV medication due to continued lack of viral suppression.
In some ways, COVID-19 made my ability to connect with Raquel more difficult and certainly impeded her getting the blood work done, which is normally drawn at a clinic visit. However, in some ways, the outbreak may have given me and her other healthcare providers more opportunities and license to communicate with her. Also, being at home rather than continuing to juggle work, family, and online courses may have made it easier for her to better adhere to her HIV medication. Most of us only know the face-to-face model of care we learned in school, and we certainly need to be able to see, examine, and connect with our patients—especially those most at risk of virologic failure. However, I am learning during this surreal time that sometimes we can do a lot from a distance and that absence really can make the heart grow fonder.
How has the COVID-19 pandemic affected your ability to retain patients in care? Please answer the polling question and share your thoughts in the discussion section.