Table 3 Other illustrative participant quotations by result categories

1. Reasons for referral

 Secondary CVD prevention

…if they need stenting or a bypass then obviously, we need them to follow with a cardiologist. …If they have established CVD, I prefer that they're also under the care of a cardiologist. …Heart failure is another one, heart failure management is best done in conjunction with a cardiologist. [HIV provider, 1 year HIV experience]

 Uncontrolled CVD risk factors

It’s more dependent on whether they’re responding to therapy or not. So, the discomfort comes in patients who are not responding to primary therapy. I think the best way to explain it would be that I am familiar with treatment of blood pressure, but in patients who don’t respond well to initial attempts to control blood pressure, I’m less comfortable with pursuing the next steps. …It’s more whether or not they’re responding to the therapies that I’m providing and whether I need help in that. Most likely, I need help in patients who …need blood pressure control and the blood pressure’s not getting under control. [HIV provider, 29 years HIV experience]

 Suspected cardiac symptoms

I think that if they are having chest pain, I get nervous as all heck and so that is definitely a reason for me to refer someone to a cardiologist as well. If they’re having kind of chest pain where it’s atypical or not. [HIV provider, 16 years HIV experience]

 Medication management

I am comfortable with most of them. Where it gets confusing is when they start needing more than one or two medicines. People who have really refractory hypertension and I start getting into four different blood pressure medicines and they’re still needing help. That’s where I start to get a little nervous that they should be going to a hypertension clinic for example. [HIV provider, 16 years HIV experience]

2. Facilitators of an optimal specialty referral process

Knowing that they have insurance is the biggest thing and the second biggest thing is having somebody to facilitate the referral for me….. [HIV provider, 10 years HIV experience]

Well, if they live close-by, if they have insurance, all of those things make it much easier. [HIV provider, 13 years HIV experience]

Well, I think for any referrals in the broadest sense, it helps if I know someone in the field who wants to do this type of care. So, some referrals are easy because I know the provider who likes to work with my patients and maybe has an interest in caring for people with HIV or just is generally eager to receive patients. Those are some of the things that make it easy. [HIV provider, 29 years HIV experience]

3. Barriers to an optimal specialty referral process

 Transport and time barriers

… [O]ne factor can be issues like – we don’t as a matter of rule for everybody provide let’s say transportation services. So, if someone has to come to clinic, sometimes it’s gonna cost them $1 or $2 or more to take a city transport. That actually pops into my brain as – we hear more about that in terms of socioeconomic limitations. It isn’t that – their visit would be covered. They would have no expense for their blood work or their visit, but they don’t have the $3 in order to get to the visit where my care would be free. [HIV provider, 23 years HIV experience]

 Financial barriers

People do talk about insurance and whether or not it's covered. That's probably the most frequent response I get, is “Well, is it covered?” [HIV provider, 10 years HIV experience]

 Stigma, having to disclose HIV status

I don't think I’ve had them [HIV patients] express serious concerns about seeing a cardiologist. I think sometimes they just – anytime there’s a new provider, more so I think in a primary care, they may not feel like they have the best relationship or it’s just another person they have to kind of get used to. I also will say that I think stigma is an issue for a number of patients. And they are concerned about going to a primary care provider locally when it’s gonna say HIV on their chart. So, that actually is a significant barrier for a number of people, particularly if they live in a small rural community. … [T]hey may not want to be seen really by anyone locally because they would feel compelled to disclose their HIV status as part of their non-HIV medical care. [HIV provider, 24 years HIV experience]