HIV in primary care: Treating an aging epidemic
■ As HIV-positive patients live longer due to improved treatments, they are developing chronic diseases that need to be managed by primary care doctors, experts say.
When Victoria Sharp, MD, was a medical resident in New York City in the early 1980s, people often came to the emergency department with complaints of shortness of breath from climbing subway stairs.
Two weeks later, they would be dead.
Those were the early days of AIDS, when nearly everyone who developed the disease contracted an opportunistic infection and died shortly thereafter.
Today, 30 years after the Centers for Disease Control and Prevention published a report on the first known cases of AIDS, infected patients rarely die of the disease. Instead, many people lead long lives after being diagnosed with HIV -- some living well into their 90s. When they die, it often is from the same conditions as people who are not infected.
Medical advancements have led some infectious diseases experts to laud the treatment and care of people with HIV as one of the greatest medical success stories of the 20th century.
"In the course of our careers, we've seen a disease [transition from] one for which we used to basically do a deathwatch for patients to now keeping our infected patients out of the hospital and back at work. It's amazing," said Dr. Sharp, director of the Center for Comprehensive Care in New York City. The center is an HIV/AIDS clinic at St. Luke's/Roosevelt Hospital.
Due in part to this progress, care for HIV/AIDS patients has shifted from specialists to primary care physicians. Effective treatments have enabled patients with the disease to live long enough to develop chronic health conditions, such as arthritis, diabetes and hypertension, that are common among aging patients in primary care.
Additionally, experts anticipate that there soon will be a shortage of HIV/AIDS medicine specialists, which will lead even more infected patients to the offices of family physicians and internists.
Of the 3,155 U.S.-based members of the HIV Medicine Assn., 45% are older than 50, according to a March 17 Institute of Medicine report on HIV screening and access to care.
The IOM said that as these experts approach retirement, many are downsizing or leaving their practices.
Complicating matters, there are not enough new physicians entering the specialty to address the needs of the growing number of Americans living with HIV/AIDS, the IOM said.
As a result, the responsibility of treating these patients is expected to fall increasingly to primary care physicians. Infectious diseases experts encourage doctors to participate in training opportunities and form relationships with local HIV/AIDS specialists to ensure they have a basic understanding of the disease.
"There really is going to be a crisis in care [for HIV/AIDS patients] if we can't get people in general medicine to understand that they can do good general HIV care with some backup of specialists," said Donna Sweet, MD, an HIV/AIDS specialist and professor of internal medicine at the KU School of Medicine-Wichita.
Challenges of treating HIV
In 2008, an estimated 1.1 million Americans age 13 and older were living with HIV and 21% did not know they were infected, according to the CDC's most recent figures.
Health professionals are testing more people for the virus in light of the CDC's 2006 recommendation to test everyone between age 13 and 64.
By 2015, the IOM estimates that half of Americans living with HIV/AIDS will be older than 50. For primary care doctors, this means a growing number of their patients will need care for chronic diseases as well as HIV.
Treating the autoimmune disease is easier than it was in the early 1990s, when Tucson, Ariz., family physician J. Kevin Carmichael, MD, managed drug cocktails that contained handfuls of pills with often severe side effects. But he said there still are significant challenges in caring for infected patients.
Among those challenges is selecting the most appropriate antiviral regimen for patients from the more than 20 drugs available to treat the infection, said Dr. Carmichael, an HIV/AIDS specialist.
Standard antiretroviral therapy consists of the use of at least three drugs to maximally suppress the HIV virus and stop the progression of the disease, according to the World Health Organization. Treatment becomes more complicated when patients have chronic diseases, because drugs used to manage those conditions often interact with the antiretrovirals.
Dr. Carmichael said physicians have to be aware of the increased prevalence of mental illness and substance abuse among HIV/AIDS patients. He noted that such patients also have a heightened risk of cardiovascular disease and diabetes than those without HIV.
"A primary care physician needs to be aware of all the conditions they would expect in their population that doesn't have HIV and then think about all the potential complications that can be associated with HIV and HIV therapies," said Judith Aberg, MD, chair-elect of the HIV Medicine Assn. and director of the Division of Infectious Diseases and Immunology at the NYU School of Medicine. "It's a tall order to really understand this."
Managing HIV-positive patients
New York internist Jeffrey Engel, MD, tries to stay abreast of developments in HIV/AIDS medicine by reading new studies and attending educational sessions. Such sessions include those offered by the American College of Physicians at the organization's annual meeting.
He said he gained much of his experience treating HIV-positive patients as a medical resident in the 1990s in New York.
Dr. Engel cares for about 100 people with HIV in his private practice, which has several thousand patients. His greatest challenge is ensuring that patients with the disease take their medicine properly.
Poor adherence can produce mutations in the virus that are resistant to the patients' treatment. To promote compliance, Dr. Engel meets with his HIV-positive patients at least four times a year. During these visits, he tests the individual's viral load, the amount of virus in the blood.
If the viral load increases over several measurements, Dr. Engel sometimes refers the patient to an infectious diseases specialist who can determine the cause of the problem and initiate the most appropriate new medication regimen for the individual.
Dr. Aberg encourages all primary care doctors to know their limits when it comes to treating HIV/AIDS.
"Primary care physicians need to [ask themselves], 'How much knowledge do I have on this disease and about these drugs? Who can I refer to to help me manage this patient?' " she said.
But, she added, all physicians should know enough about the disease to feel comfortable testing patients for HIV and answering general questions about the illness.
In 2009, a record 82.9 million American adults were tested for HIV -- 11.4 million more than in 2006, according to CDC figures released in December 2010 for World AIDS Day.
Even so, 55% of adults, including 28% who are considered at high risk for contracting the virus, have never been tested, the CDC said. Risk factors include engaging in unprotected sex, having another sexually transmitted disease and using intravenous drugs.
The earlier people are diagnosed with HIV, the sooner they can start antiretroviral therapy, which dramatically decreases the risk of transmitting the infection through sexual activity.
Experts recommend that physicians ask patients about HIV testing during office visits when they discuss other behaviors such as smoking and sexual activity. When a test comes back positive for HIV, Dr. Sweet, of the KU School of Medicine, urges doctors to schedule an appointment with the patient to confirm the findings with a second test and then discuss the results.
She recommends that physicians be optimistic and tell patients, "We can control this infection for you. We can change your prognosis and give you decades of life."
At the HIV/AIDS clinic where Dr. Carmichael works, about 90% of the patients have undetectable viral loads. Very low levels of the virus can be obtained when health professionals prescribe the proper antiviral regimen and when patients take the medication as prescribed, Dr. Carmichael said.
He also attributes his patients' success to the clinic's comprehensive on-site services that extend beyond medical care to treatment of mental health and medication adherence problems. He worries that as HIV/AIDS care transitions more into the hands of busy primary care doctors, these patients' needs will not be met.
Chicago internist Eric Christoff, MD, however, considers primary care an appropriate place for HIV/AIDS care.
He said HIV-positive patients struggle with chronic diseases, medication adherence and mental illness, all of which are regularly addressed in primary care.
"[They] can have [health] issues that run the spectrum of all the disorders we learn how to manage capably," said Dr. Christoff, an internal medicine physician with the Northwestern Memorial Physicians Group and an HIV/AIDS specialist. Treating these patients "fits into our specialty quite well."