An Assessment of Telehealth Utility and Attitudes in Infectious Disease Patients

Abstract

Background:

Persons living with HIV (PWH) experience numerous barriers to care and require routine follow-up, lab testing, and preventative care to maintain their health. Since 2020, telehealth has been widely and rapidly implemented across all health fields, changing the delivery of care. Preliminary data show that PWH experienced increases in their viral load counts and decreases in appointment frequency during 2020. There are limited studies on the current telehealth practices of PWH. This study aims to investigate the effect of current telehealth usage, attitudes, and accessibility on short-term health outcomes among patients attending a diverse infectious disease clinic.

Method:

A 45-question cross-sectional qualitative survey study was open to patients attending in-person appointments at MedStar Georgetown University Hospital Infectious Disease outpatient clinic from August 2022 to August 2023. All adult, nonpregnant, nonincarcerated patients with at least 1 appointment at the infectious disease clinic were eligible to participate.

Results:

Of the 129 surveyed patients, 96.9% (n = 126) had access to an internet-capable device, and 57% (n = 74) had at least 1 telehealth appointment within 6 months of survey completion. 40.3% (n = 52) of patients had appointments relating to the treatment and prevention of HIV. Among surveyed patients, all telehealth modalities were favorably viewed; however, both asynchronous telehealth and synchronous video were significantly preferred to audio-only services (mean: 3.86, 3.79, 3.38, respectively, p < 0.01). Younger patients (<60 years old) rated asynchronous telehealth modalities significantly higher than their 60+ counterparts (p < 0.05). Self-identified Black participants were significantly more likely to prefer audio-only telehealth services compared to non-Black patients (mean: 3.76 vs. 3.18, p < 0.05).

Discussion:

There have been limited studies investigating the continued use of telehealth services following the widespread uptake of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination in 2021 in terms of accessibility and patient attitudes. This study supports that telehealth services are still used and favored by surveyed patients. When stratified by race, Black individuals were significantly more likely to prefer audio-only calls, which was inconsistent with the overall favorable view of video visits by the surveyed population at large. The ideal modality of virtual health care needs further exploration.

Introduction

Telehealth and telemedicine can be defined as providing clinical services to patients without an in-person visit, typically using the internet via a computer, phone, or tablet.^1,2 Prior to the SARS-CoV-2 pandemic in 2020, the interest and integration of telemedicine into clinical practice were slowly rising. Most US hospital systems were using a form of telemedicine to provide and augment patient care, with some systems implementing comprehensive clinical services via remote modalities.^1,3,4 However, access to these services was limited, especially in rural areas of the United States, and usage was largely restricted to certain specialties (cardiology, psychiatry, and radiology).⁵ Patients generally had favorable views of this emerging modality despite concerns over data security and care quality.¹

Despite patient favorability and interest, provider barriers in reimbursements, privacy regulations, and interstate licensing restrictions limited widespread telemedicine uptake prior to 2020.¹ Following changes in legal limitations and public health measures occurring during the onset of SARS-CoV-2, the usage of telemedicine for comprehensive service delivery, including the conduct of clinical visits, increased 766% within the first 3 months of the pandemic.¹ This rapid, widespread implementation of virtual care left many vulnerable populations without health care continuity due to social and technological disparities.⁶

Among outpatient infectious disease patients, research suggested variability in the impact of telehealth services based on disease chronicity and required follow-up. Acute infections treated via telehealth consultation were subject to increased rates of antibiotic prescription due to limitations in physical examinations and testing.⁷ However, the impact of telehealth on those living with chronic infectious diseases, including patients with hepatitis C, tuberculosis, and HIV, who require stable and regular follow-up, shifted toward appointment adherence and latency of disease and appeared to benefit from virtual services to varying degrees.^8,9

Among those living with a chronic infectious disease in the United States, it is estimated that over one million people are infected with HIV, with over 32,000 new cases being diagnosed each year.¹⁰ Although the average lifespan of a person living with HIV (PWH) is lower than the general population, HIV has transitioned into a chronically managed disease due to antiretroviral therapy.¹¹ As this population ages, it has been found that PWH experience higher rates of cardiac disease, kidney disease, and osteoporosis compared to the general population.¹² With the implementation of the Affordable Care Act in 2014 and Medicaid expansion in certain states, more PWH, who were previously uninsured, have been able to receive non-HIV care.¹³ In spite of this, PWH continue to experience significant barriers, often in the context of a high prevalence of concurrent substance use and mental health problems.¹⁴ Stigma at every stage of HIV treatment, from diagnosis to long-term care, is a risk factor for a worse prognosis.¹⁵ PWH who perceive HIV-related stigma are 2.4 times more likely to delay care, leading to late initial disease presentation and increased morbidity and mortality.¹⁵

Limited research suggested that the shift in health care delivery to remote modalities at the start of the SARS-CoV-2 pandemic uniquely impacted PWH as maintenance of undetectable HIV viral loads and appointment adherence declined overall.^6,16 This was in part due to a lack of access to necessary technology along with social determinants including unstable housing and a decline in social support services.⁶ Even if virtual visits were completed, the lack of access to necessary devices for the appointments was associated with decreased quality of care, often leading to a limited range of health services via audio-only phone calls.¹⁷ Within the PWH population, racial and age disparities also arose to show Black patients and patients from other minority groups were less likely to use telehealth services, while younger patients were less likely to attend virtual phone visits.^18,19 Mistrust of the health care system that persisted prior to the SARS-CoV-2 pandemic was highlighted at the start of telemedicine’s widespread use. PWH, especially over age 50, expressed concerns regarding privacy and lack of interpersonal communication on devices, which resulted in a majority of patients across multiple studies negatively viewing the utility of telemedicine.^20,21

To date, there are limited data on the impact of telehealth and its longevity as a clinical tool now that medicine has entered a hybrid delivery of care since the implementation of the COVID-19 vaccine in 2021. In the development and implementation of this cross-sectional survey study, we explore the current technological disparities in telehealth usage, access, and attitudes among infectious disease medicine patients. In this single-site study, we evaluate the current engagement in telehealth in an infectious disease clinic and identify barriers created by this shift in health care. We moreover explore patient opinion on the utility of telehealth to ultimately improve the quality of telehealth services for PWH.

Methods

A 45-question cross-sectional survey (Supplementary Appendix SA1) was developed to evaluate the usage, attitudes, and access to telehealth, including synchronous (real-time video), asynchronous (portal messages and SMS), and audio-only modalities among infectious disease clinic patients. Questions were developed from existing published surveys on PWH and included questions regarding self-reported demographic and health information, accessibility of telehealth services (Do you have consistent access to a computer, tablet, wearable device, or cell phone?), usage of services (In the past 6 months, did you have a telehealth visit?), and perception of services (How did your telehealth/telemedicine visit compare to an in-person visit?) comparing infectious disease and primary care visits.^20,21 Previously validated questions were used when available. Questions were coded and streamlined into Qualtrics to optimize participant experience. The survey was reviewed and approved by the Georgetown/MedStar Institutional Review Board.

Our patient population included all adult, nonpregnant, nonincarcerated patients who had at least 1 in-person appointment at the MedStar Georgetown University Hospital Infectious Disease Clinic. The survey was self-administered on a tablet while the person was in the waiting area and was facilitated by research associates. Each survey respondent underwent an informed consent process, which included written documentation of the risks and benefits of participation in the study (Supplementary Appendix SA1).

Survey analysis was conducted via several statistical methods, including summary numbers, frequency tables, chi-squared, t-tests, analysis of variance, and Mann–Whitney tests when applicable. The primary outcome of this survey was to evaluate the usage and patient attitudes toward telehealth services. The secondary outcome was to evaluate the utility of questions for future use in a multisite intervention of an HIV patient cohort.

Results

Data were collected over a 1-year period from August 2022 to August 2023, with a total of 129 complete responses. As seen in Table 1, the median age of participants was 56 years, ranging from 18 to 83, with the majority of patients being between 41 and 64 years. The male-to-female ratio was 1.6:1. 53.5% of participants identified as White, 36.4% of participants identified as Black, and 20.2% identified as Latinx. Among participants, 96.9% (Fig. 1A) of respondents stated having consistent access to a technology device. Similarly, 96.1% (Fig. 1B) have a device that can connect to the internet.

FIG. 1.

(A) “Can your device connect to the internet?” Internet connectivity of surveyed population, n = 129. (B) “Does the device have video capability?” Internet and video capability of the surveyed population, n = 129.

Table 1.

Participant Characteristics

Characteristic	Participants: 129 No. (%)
Age	Median: 56
18–24	9 (7)
25–29	4 (3)
30–39	17 (13)
40–49	18 (14)
50–59	26 (21)
60+	50 (39)
Sex at birth
Male	79 (61)
Female	49 (38)
Decline	1 (<1)
Race/ethnicity
White	69 (53)
Black	47 (36)
Asian/Pacific Islander	6 (5)
Native American	1 (<1)
Other	6 (5)
Hispanic/Latin/a/x
Yes	26 (20)
No	103 (80)
Education
Grades 1–11	2 (2)
High school/GED	43 (33)
Bachelor’s	38 (29)
Master’s	30 (23)
PhD or higher	15 (12)
Annual household income
Less than $25,000	12 (9)
$25,000–$99,999	35 (27)
$100,000–$199,999	40 (31)
More than $200,000	21 (16)
Risk for homelessness
Yes	10 (8)
No	110 (85)

GED, General Educational Development.

Of the appointment types, 46 participants (35.7%) had appointments for HIV care (Table 2). Within this population, 92.2% of patients had undergone viral load (VL) blood tests within the previous 6 months of survey completion, and 82.6% of patients had self-reported undetectable HIV viral loads from their most recent blood draw. More PWH than persons without HIV had received their influenza vaccination within the past year (89.1% vs. 75.6%, p = 0.064; Fig. 2). Among PWH, there was no statistically significant association between receipt of influenza vaccination and undetectable HIV VL (85.4% vs. 75.0%, p = 0.40, Fig. 2, Supplementary Table S1).

FIG. 2.

Reception of influenza vaccine stratified by appointment type (HIV treatment, other visit). “Other visit” includes any infectious disease appointment that was not related to HIV care. PWH were further stratified by viremic status (undetectable VL, detectable VL). PWH, persons living with HIV; VL, viral load.

Table 2.

Conditions Surveyed Population Are Seen for at Infectious Disease Clinic

Appointment type	No.	%
HIV treatment	46	35.7%
Hepatitis B or C	5	3.9%
Transplant	8	6.2%
Bacterial infection (abx <6 weeks)	12	9.3%
Bacterial infection (abx >6 weeks)	17	13.2%
Travel	9	7.0%
Lyme disease	0	0.0%
HIV prevention (PrEP or PEP)	8	6.2%
Hospital follow-up	10	7.8%
Other	30	23.3%
Total patients	129

Respondents may be treated for more than one condition in the infectious disease clinic and instructed to check all conditions that applied.

Abx, antibiotics; PEP, non-occupational post-exposure prophylaxis; PrEP, Pre-exposure prophylaxis for HIV

Among all survey respondents, 59.0% reported having at least one telehealth appointment within the previous 6 months of survey completion. When stratified by HIV status, significantly fewer PWH had telehealth appointments than persons without HIV (45.7% vs. 66.3%, respectively, p = 0.024, Fig. 3). However, there was no difference in whether telehealth appointments were conducted on video among persons with and without HIV (81.0% vs. 90.6%, respectively, p = 0.25).

FIG. 3.

Percentage of surveyed population with at least one telehealth appointment within 6 months of survey completion, stratified by HIV status. *p < 0.05.

When asked to compare the telehealth visit to their in-person visits, overall, only 7.4% of total respondents found their infectious diseases virtual appointments to be “worse” than their in-person experiences, compared to 17.3% of respondents who reported their primary care virtual appointments to be “worse” than in-person appointments (p = 0.035, Supplementary Table S2). Among PWH, there was no statistical difference in reports that indicated “worse” experiences with primary care compared with infectious diseases telehealth (10.0% for infectious diseases vs. 16.2%, for primary care, p = 0.42, Supplementary Table S2).

When considering the likelihood to recommend telehealth appointments, the majority of participants recorded a positive response to recommending a primary care or infectious disease telehealth visit (56.9% and 56.7%, respectively; Supplementary Table S3). However, fewer PWH indicated they would recommend their infectious diseases telehealth visit to be conducted via telehealth compared to persons without HIV, but this did not reach the level of statistical significance (48.7%, 61.2%, respectively, p = 0.21, Supplementary Table S3). When asked to consider the future of these virtual services, 48.3% and 48.7% of all respondents indicated that having the option for telemedicine appointments in the future would be extremely useful for both primary care and infectious disease visits, respectively.

Among patients who had experienced a recent telehealth appointment, there was a significant difference in patient perceptions of different telehealth modalities (Table 3). While phone (audio-only) visits, compared to other telehealth modalities (video and asynchronous), were less likely to be recommended by the overall population (mean: 3.38, 3.79, 3.86, respectively, p < 0.01, Table 3), there was no discernible preference for telehealth modality among PWH (PWH mean: 3.51, 3.71, 3.76, respectively, p = 0.65, Table 3). There were statistically significant differences among subpopulations by age and race: self-identified Black patients were more likely than persons of other races to recommend phone-only visits (mean 3.76 vs. 3.18, p = 0.021, Table 4). This difference was not seen among Black PWH who were equally likely to recommend phone-only visits compared to Black persons without HIV (3.61 vs. 4.00, p = 0.32, Table 4). There was no difference in PWH with detectable VLs compared with those with undetectable VL in recommending video and audio-only telehealth visits (4.00 vs. 3.76, p = 0.29, 4.00 vs. 3.42, p = 0.65, respectively, Supplementary Figure S1).

Table 3.

Attitudes Toward Telehealth Modalities (Phone, Video, Asynchronous) Stratified by Demographics, Health Outcomes, and Accessibility

		How likely are you to recommend?Scale 1–5 (Not at all likely–Definitely)
		Phone (audio-only) Visits		Video visits		Asynchronous
Characteristic	n	Mean rating	p	Mean rating	p	Mean rating	p
All	129	3.38	0.009^*	3.79	—	3.86	—
Race
White	69	3.21	0.410	3.80	0.947	3.94	0.666
Black	47	3.76	0.108	3.78	0.950	3.67	0.408
Asian/Pacific Islander	6	2.50	0.127	3.00	0.155	3.50	0.490
Other	7	3.43	0.933	4.40	0.200	4.67	0.113
Hispanic/Latin/a/x
Yes	26	3.08	0.217	3.46	0.166	3.61	0.279
No	103	3.46	—	3.87	—	3.92	—
Annual household income
Less than $50,000	26	3.21	0.403	3.38	0.090	3.54	0.116
More than $50,000	81	3.48	—	3.88	—	3.99	—
HIV status
In HIV treatment	46	3.51	0.601	3.70	0.756	3.76	0.686
Not in care for HIV	83	3.31	—	3.78	—	3.86	—
Viral suppression
Detectable viral load	8	4.00	0.293	4.00	0.647	3.80	0.918
Undetectable viral load	38	3.42	—	3.76	—	3.86	—
Access to internet
Yes	126	3.41	0.179	3.79	0.871	3.87	0.318
No/unsure	3	2.33	—	3.67	—	3.00	—
Risk for homelessness
Yes	10	4.00	0.113	4.22	0.231	3.63	0.653
No	111	3.25	—	3.70	—	3.83	—
Education
High school/GED or below	45	3.47	0.648	3.79	0.987	3.83	0.816
Bachelor’s or greater	82	3.35	—	3.79	—	3.88	—
Employment
Full time	60	3.36	0.693	3.71	0.384	3.98	0.450
<Full time	66	3.46		3.92		3.81

Respondents used a 5-point Likert scale to indicate preference. 1 = Definitely DO NOT Recommend; 5 = Definitely Recommend.

p < 0.05.

Table 4.

Attitudes Toward Telehealth Modalities (Phone, Video, Asynchronous) Stratified by Race, and Further Stratified by HIV Status

	How likely are you to recommend the following telehealth visitsScale 1–5 (Not at all likely–Definitely)
	Phone (audio-only)		Video		Asynchronous visits
	Mean rating	p	Mean rating	p	Mean rating	p
Race
Black	3.76	0.021^*	3.77	0.928	3.67	0.215
Other	3.18	—	3.79	—	3.96	—
HIV status^a
HIV	3.61	0.317	3.64	0.471	3.45	0.171
No HIV	4.00	—	3.94	—	4.05	—

Respondents used a 5-point Likert scale to indicate preference. 1 = Definitely DO NOT Recommend; 5 = Definitely Recommend.

p < 0.05.

Black identifying patients only.

Overall, younger patients were significantly more likely to recommend asynchronous updates than those older than 60 years of age (4.00 vs. 3.60, p = 0.047, Table 5, Fig. 4). There was no difference in likelihood to recommend asynchronous updates comparing younger and older (over age 60 years) among PWH (3.81 vs. 3.71, p = 0.84, Table 5).

FIG. 4.

Likelihood of survey population to recommend phone, video, and asynchronous modalities of telehealth services stratified by age. Respondents used a 5-point Likert scale to indicate preference: 1 = Definitely DO NOT Recommend; 5 = Definitely Recommend. *p < 0.05.

Table 5.

Attitudes Toward Telehealth Modalities (Phone, Video, Asynchronous) Stratified by Age, and Further Stratified by HIV Status

	How likely are you to recommend the following telehealth visitsScale 1–5 (Not at all likely–Definitely)
	Phone (audio-only)		Video		Asynchronous visits
	Mean rating	p	Mean rating	p	Mean rating	p
Overall age (years)
<60	3.33	0.770	3.62	0.300	3.60	0.047^*
≥60	3.40	—	3.82	—	4.00	—
PWH age (years)
<60	3.44	0.841	3.81	0.443	3.81	0.842
≥60	3.53	—	3.47	—	3.71	—

Respondents used a 5-point Likert scale to indicate preference. 1 = Definitely DO NOT Recommend; 5 = Definitely Recommend.

p < 0.05.

Discussion

The rapidly changing landscape of health care in 2020 created a robust space for virtual medical practice to avoid the risk of COVID-19 infection through close contact with others in a health care setting. As vaccination rates against SARS-CoV-2 increased, health care services began to offer more in-person appointments in addition to telehealth, creating a hybrid environment that increased patient-centered care. To date, there have been limited studies investigating the continued use of and patient attitudes toward telemedicine as a method for maintaining continuity of care in infectious disease settings.

As seen by the results of this study, telehealth services are still used and favored by patients attending in-person infectious disease appointments with a noted preference for video visits over other virtual modalities of care. The significant preference for audio-only visits among Black respondents was unexpected, and further investigation is needed to explore causes, including the possibility of decreased practitioner bias or increased flexibility of appointment. This finding also uncovers the question of whether video visits should be considered the highest quality of virtual care, as previously reported, given these noted preferences.²¹

In this study, the majority of survey respondents living with HIV had undetectable VLs, indicating a well-controlled HIV infection, and can be an indication that patients are well connected to care. PWH using significantly less telehealth services than non-HIV patients may be due to a higher burden of necessary in-person appointments for close monitoring of VLs.

We observed high uptake of influenza vaccination among this population that suggests continued connection and access to in-person health care services, even while using telehealth services. Persons with detectable viral loads trended toward favoring telehealth services and proportionally had a lower rate of influenza vaccination compared to those with undetectable virus. This suggests PWH with detectable virus might have had less access to or were less likely to make use of in-person services in general. For this population, the flexibility in time and location of telehealth services may have expanded health care when appointment attendance and adherence would otherwise not have been possible. This may be a population in which the continued provision of telehealth services would be beneficial, in addition to further support to ensure adherence to antiretroviral therapy and accessibility to necessary in-person services, including laboratory testing and preventative health care.

While the finding that telehealth services may have increased health care utilization for some populations deviates from previous studies investigating health maintenance among PWH during the pandemic, the majority of the studies previously reported were set from 2020 to 2021.^6,19–21 The high percentage of patients reporting both recent viral load testing and undetectable status suggests the hybrid in-person/telehealth model during our study period may have led to more access and successful maintenance of HIV care. Considering that the high percentage of influenza vaccination suggests that this hybrid model allowed for continuity of care of preventive services, these findings should be investigated further.

There were several limitations to this study. As a single-site survey, the demographics and technological access may not represent the general District of Columbia or US population. The survey was also limited to patients attending in-person appointments at an infectious disease clinic only. This may have affected the opinions and attitudes expressed toward telehealth services. It should lastly be acknowledged that while the self-reported health information included in the survey may have been subject to recall bias and misreporting by respondents, the nature of the survey that called for self-administration may have allowed persons to be more open with their overall experiences. Interviewer stigma and judgment could have led to misreporting.

Conclusion

Telehealth was largely accessible to survey respondents and was associated with high health service usage, including among those who received at least some health care services in the in-person setting, as reflected by our survey population. Participants included in this study were in favor of continued access to virtual health care options for both primary care as well as infectious diseases services. Exploration into the ideal modality of virtual health care that ensures comprehensive service delivery needs further attention.

Footnotes

Authorship Contribution Statement

G.Y.: Methodology (lead), investigation (lead), writing—original draft (lead), conceptualization (supporting), and visualization (equal). A.V.: Conceptualization (lead), writing—review and editing (equal), project administration (equal), and supervision (equal). D.P.: Investigation (supporting) and writing—review and editing (supporting). M.A.: Investigation (supporting). C.H.: Formal analysis (lead) and visualization (equal). S.K.: Supervision (lead), project administration (equal), writing—review and editing (equal), and funding acquisition (lead).

Author Disclosure Statement

All authors declare they have no conflicts of interest to disclose.

Funding Information

This study is supported by the Metropolitan Washington CRS (Seble Kassaye and Adam Visconti) U01-HL146205, UL1-TR001409 (DC CTSA), KL2-TR001432 (DC CTSA), TL1-TR001431 (DC CTSA), and DC Center for AIDS Research (P30AI117970). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Supplementary Material

Abbreviations Used

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Supplementary Material

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