Geographic access and use of infectious diseases specialty and general primary care services by veterans with HIV infection: implications for telehealth and shared care programs.
OBJECTIVE
Rural-dwelling persons with HIV infection often have limited access to HIV specialty care, and they may instead use more nearby primary care. This study described use of infectious disease (ID) specialty and general primary care services among rural compared with urban veterans with HIV in the United States and determined associations between geographic access to ID and primary care and use of care.


METHODS
The sample included all veterans in the national Veterans Administration (VA) HIV clinical case registry in 2009 (N = 23,669, 10.2% rural). Geographic access was measured by calculating travel times to the nearest VA primary care and ID specialty clinic.


RESULTS
Rural veterans were less likely than urban to use ID clinics (82% of rural vs 87% of urban, P < .01) and more likely to use primary care (82% vs 73%, P < .01). As travel time to ID care increased from less than 15 minutes to over 90 minutes, use of ID care decreased from 88% to 71% (P < .01), while use of primary care increased from 68% to 86% (P < .0001). In multivariable models, increased travel time to ID care-but not rural residence-was associated with decreased ID and increased primary care use.


CONCLUSIONS
Persons with HIV who live far from ID specialty clinics are less likely to use specialty care and more likely to use primary care. Specialty clinics should consider using telehealth to deliver care over distance and programs to coordinate "shared care" relationships with distant primary care providers.
VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Central Region, Iowa City VAMC, Iowa City, Iowa; Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VAMC, Iowa City, Iowa; Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa.
Michael E
ME
Ohl
Kelly
K
Richardson
Peter J
PJ
Kaboli
Eli N
EN
Perencevich
Mary
M
Vaughan-Sarrazin
D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D005843:Geography; D015658:HIV Infections / Q000628:therapy*; D006297:Health Services Accessibility / Q000592:standards*; D006801:Humans; D055552:Infectious Disease Medicine; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012424:Rural Population; D017216:Telemedicine / Q000639:trends; D014481:United States; D014493:United States Department of Veterans Affairs / Q000639:trends; D014728:Veterans / Q000706:statistics & numerical data*
HIV; access to care; geography; health services research; rural health