Editorials

Preventing HIV- A Primary Care Imperative

RONALD H. GOLDSCHMIDT, M.D.
San Francisco General Hospital
San Francisco, California

REBECCA E. POAGE, M.D.
Georgetown University Medical Center
Washington, D.C.

See article on page 295.

How deceptive appearances can be! Maria resembled all the other young, healthy women who receive prenatal care at our clinic. She seemed to be a low-risk 18-year-old. She was in her first romantic relationship and, although her pregnancy was unplanned, she was happy about it. Her boyfriend was supportive and came to all her prenatal visits. In early pregnancy, Maria tested negative for human immunodeficiency virus (HIV) infection and later had an uncomplicated vaginal delivery. Her vigorous infant breastfed well, and they were discharged on the second postpartum day.

At the two-week follow-up visit, the baby had prominent inguinal and cervical lymphadenopathy. The precepting attending, a family physician with extensive experience in HIV care, agreed with the plan to include HIV infection as part of the diagnostic work-up. A week later, tests confirmed that the baby had acute HIV infection.

Unbeknownst to all of us, Maria had seroconverted during her otherwise unremarkable pregnancy. The father, who was surprised to learn of his HIV-positive status, left Maria a few months later. At last report, mother and child were doing well with treatment.

This tragic case of heterosexual HIV transmission and the resulting, entirely preventable, case of perinatal HIV transmission illustrates the need for improvements in HIV prevention strategies. Several important developments in HIV prevention seek to address this need.

The Centers for Disease Control and Prevention (CDC) recently published a new initiative calling for wider testing, including counseling and testing as part of routine primary care, intensified counseling and education for patients with HIV and their partners to prevent new infections, and increased measures to prevent perinatal transmission.1,2 The article by Gallant3 in this issue of American Family Physician summarizes essential components of these initiatives and provides valuable information about HIV testing.

Improved rapid HIV testing is the newest tool that promises to make our prevention efforts easier and more effective. Current rapid HIV tests have near-zero rates of false-positive and false-negative results. Although they still require confirmation to establish a final diagnosis, they are sufficiently accurate for guiding clinical decisions and informing patients of the results with near-complete confidence.

HIV testing has traditionally relied on standard antibody test confirmation, a process that generally takes two weeks. The percentage of tested persons who fail to return to find out their test results has been unacceptably high. During 2000, 31 percent of persons who tested positive for HIV infection did not return to learn their results.2 Many of these patients did not receive follow-up care and were not aware of their need to take measures to prevent transmission of HIV infection to others. The highly accurate, rapid HIV tests make it possible to provide same-visit guidance in urgent situations (such as labor and delivery,4 occupational exposures, and sexual assault) and in routine primary care.

We also can anticipate a shift in strategies to prevent perinatal transmission in the United States. The Institute of Medicine (IOM) has recommended that HIV testing be a routine (and expected) part of prenatal care so all pregnant women are tested for HIV, not just those identified as having risk factors.5 In traditional prenatal testing, women are offered an HIV test and can "opt in," or choose to be tested. Under the approach that is recommended by the IOM and now also the CDC, women would receive HIV testing as a routine part of prenatal care unless they choose to "opt out" of the test. This shift in prenatal testing strategy will require an appreciation of the ethical issues in prenatal and perinatal testing6 and the potential impact of positive results on the patients and their families.

Many of the 40,000 annual new HIV infections in the United States represent missed prevention opportunities, and hundreds of thousands of Americans still do not know that they are infected with HIV. By integrating HIV counseling and rapid and standard HIV testing into their routine clinical practice, family physicians and other front-line clinicians can and should take a leading role in HIV infection prevention.

References

The Authors

Ronald H. Goldschmidt, M.D., is director of the Family Practice Inpatient Service at San Francisco General Hospital, University of California, San Francisco.

Rebecca E. Poage, M.D., is assistant professor in the Department of Family Medicine at Georgetown University Medical Center in Washington, D.C., and medical editing fellow for American Family Physician.

Address correspondence to Ronald H. Goldschmidt, M.D., San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110 (e-mail: rongold@ itsa.ucsf.edu). Reprints are not available from the authors.

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How Useful Is the Concept of 'Failure to Thrive' in Care of the Aged?

DOUGLAS C. WOOLLEY, M.D., M.P.H.
Kansas University School of Medicine
Wichita, Kansas

See article on page 343.

In this issue of American Family Physician, Robertson and Montagnini1 review the challenges of caring for an aged patient with multiple problems whose health and vitality are rapidly declining. The term "failure to thrive," which was borrowed from health care for children to describe this accelerated decline, began appearing in the geriatric literature more than 30 years ago to denote a range of circumstances including physical and mental deterioration, abuse and neglect, and rapidly progressing frailty.

In a study2 of physicians who used the term "geriatric failure to thrive," the authors noted that it "is a term irregularly used and poorly defined." They questioned whether the concept should be used in reference to geriatric patients, fearing that it "can reinforce the stereotype of elderly people as demented and decrepit" and "may actually hinder the urgent search for treatable, reversible causes of an elder's deterioration."2 Other authors3 concluded that "the label 'failure to thrive' promotes an intellectual laziness-accompanied by a certain resignation, passivity, or fatalism." These authors3 responded with a recommendation for "the abandonment of the term 'failure to thrive' and the adoption of a more measurement-oriented approach" that explicitly assesses impaired physical function, malnutrition, depression, and dementia.

A review of MEDLINE citations and geriatric textbooks shows that, although "failure to thrive" is still a fairly common focus of authors in nutrition and nursing, it has become less prominent in the medical literature in the past six years as a central conceptualizing theme.

Contributing to concern about the use of the term "geriatric failure to thrive" are the generally vague or broad definitions, the huge clinical territory to which the term has been applied, and the difficulties of formulating a coherent research agenda. Family physicians should be wary of the application and implications of this label. First, geriatric failure to thrive should not be treated as a diagnosis or a specific disease.3 Second, it should not be equated with frailty.4 Decreased function, strength, and stamina are hallmarks of the frail aged person; however, frailty is primarily a state of increased risk and low reserve to stress, a state which all people who live into their ninth decade manifest at varying levels.4,5

Failure to thrive should be seen as an unexpected and significant falling away from the normal curve of declining vigor, weight, function, and reserve that affects even the healthiest aged persons.5 Finally, failure to thrive should not be a summary concept of a patient's situation that prompts resignation and withdrawal of efforts to find underlying causes,2 and it should not be the final clinical thought.

If the term "geriatric failure to thrive" is of any use, it is as a brief reminder to the clinician that there is major work ahead in carefully reviewing potentially reversible underlying processes in aged patients who are manifesting unexpected and unexplained declines in nutritional intake and weight, self-care, cognitive function, and interest in life. It is true that a single major problem may not be identified or, if identified, may not be reversible. However, multiple contributors often can be found, and some of them can be ameliorated; some, when thoughtfully addressed, can serve to leverage improvement in other issues that had seemed refractory.6

Encountering the unexpected and unexplained acceleration of decline in a frail aged patient gives family physicians a wonderful opportunity to do what they do best: serve as human ecologists, as expert observers and investigators, and as healers of dysfunction in a complex hierarchy comprising a biological system and an individual with a mind, feelings, and personality, who is living within a family, community, and environment.

References

The Author

Douglas C. Woolley, M.D., M.P.H., is Delos Smith Professor of Community Geriatrics at the Kansas University School of Medicine, Wichita.

Address correspondence to Douglas C. Woolley, M.D., M.P.H., Family and Community Medicine, Kansas University School of Medicine, 1010 N. Kansas St., Wichita, KS 67214-3199. (e-mail: dwoolley@kumc.edu). Reprints are not available from the author.

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