1. Clinical Management of the HIV Infected Transplant Recipient: How to Balance the Needs of the Patient and the Health Care Team

2. Clinical Management Questions z1. What are the challenges of facilitating communication among the numerous members of the study team? z2. Is it acceptable to limit access to transplantation due to geographic proximity to the transplant center because of the complex nature of the treatment involved? z3. Given the complex clinical nature of this undertaking and the busy schedules of all involved, what are the minimum components of an appropriate transplant team for the study?

3. Transplant Study Team z1. Primary HIV provider* z2. Referring Nephrologist or Hepatologist z3. Transplant Surgeons* (7) z4. HIV Study Consultant* z5. Transplant Hepatologists (7), Nephrologists (4) z6. Pre/Post Transplant Coordinators (11) z7. Study Pharmacologist* z8. Patient/family z9. Study Coordinator*

4. Purpose of Communication z1. Information Dissemination z2. Patient Scheduling z3. Decision Making

5. Communication Challenges z1. Delays in response z2. Lack of consensus z3. Shared decision making z4. Identify primary decision maker z5. Integrating theoretical information into practice z6. Access to pertinent information

6. Communication Goals z1. Facilitate discussion z2. Opportunities for interdisciplinary education z3. Shared decision making z4. Timely and efficient process z5. Positive patient outcomes

7. Limitations to Transplant z1. Selective study inclusion criteria z2. HCV co-infection z3. Economic barriers z4. Only 14 centers transplanting the HIV infected individuals z5. Geographic proximity to transplant center?!

8. Is Distance a Factor? z8 people transplanted z4 in SF area, 4 in Southern California zPatients in SF area =no rejection, no hospitalization, no SAEs zPatients out of area = all hospitalized, many complication, 2/3 rejection zCoincidental??

9. Challenges Posed by Distance z1. Variabilites between labs z2. Delays in receiving and reviewing labs z3. Delays in decision making z4. Patient management without direct assessment z5. Negotiating care plan with patient z6. Primary provider is HIV MD not Transplant MD

10. Who Should Comprise the Study Team? z1. Transplant Surgeon z2. HIV Consultant z2. Transplant Nephrologist/Hepatologist z3. Pharmacologist z4. Study Coordinator