Primary care physicians, including family physicians, are among the relatively small number of clinicians who not only regularly perform HIV screening, they also provide the majority of care for people with HIV/AIDS, says a new report from the Institute of Medicine, or IOM. And, since 2006, when the CDC recommended that HIV screening be expanded to include all people ages 13-64 who are seen in health care settings, the U.S. health care system's ability to provide those additional screenings -- let alone care for the resulting increased number of HIV-infected patients -- has become even more critically strained.
Photomicrograph of HIV-infected T cells
Because future and existing providers' training and experience in HIV care often is limited, the report -- dubbed HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care(www.nap.edu) -- calls for augmenting medical students' and residents' exposure to outpatient HIV care and providing practicing physicians more and better CME to help them address the complex health care needs of these patients.
"Greater exposure of medical students and residents to HIV patients in outpatient settings will help them develop an increased level of comfort and cultural competence in interacting with HIV-positive individuals, as well as a greater appreciation for the complexity of care such patients may require," says the IOM report.
The report recommends that starting in medical school and continuing through residency, physicians-in-training should learn the importance of taking a thorough sexual history and performing routine HIV testing.
To help boost practicing physicians' knowledge, skills and confidence in screening for, diagnosing and managing HIV infection, the report suggests that HIV/AIDS-related CME opportunities could include such activities as
- satellite learning and consultation via HIV/AIDS-related teleconferences and Web-based programs,
- mini-sabbatical training sessions,
- independent CME programs,
- HIV certification after residency, and
- HIV fellowships.
Former AAFP Family Physician of the Year William Ellert, M.D., of Scottsdale, Ariz., has for many years cared for homeless people -- including patients with HIV/AIDS -- in the Phoenix area. Ellert told AAFP News Now that when he was doing his family medicine residency at the University of Minnesota Medical Center, Fairview, in Minneapolis in the early 1990s, family physicians and internists cared for people with HIV/AIDS at a time when treatment protocols were simple and straightforward.
Now, however, because of the many advances in HIV/AIDS care made in recent years, Ellert said he -- like many other primary care physicians in similar circumstances -- refers patients to specialized centers for HIV/AIDS care, especially those that are supported by federal funding through the Ryan White HIV/AIDS Program(hab.hrsa.gov).
"Given the rapidity of change in the management of HIV patients, as well as new treatment regimens that are being developed, most family physicians feel that their patients are better served in programs that are involved with larger populations of HIV/AIDS patients and, therefore, collaborate with their colleagues involved in that type of care," said Ellert.
Family physician Condessa Curley, M.D., M.P.H., of Los Angeles, who works for the Los Angeles County Department of Public Health, told AAFP News Now she screens every patient who comes to the health department's STD clinics for HIV. For patients who test positive for the virus, she provides counseling and refers them to health care professionals who specialize in HIV care.
Curley, who counsels one or two patients a month who have been found to be HIV-positive, said physicians need to be well-educated because patients often don't understand the differences between HIV screening and confirmatory diagnostic tests. Moreover, she said, they often are misinformed about how people contract HIV infection, and they frequently have questions about preventive strategies.
In addition to screening for HIV, Curley treats patients with tuberculosis who also are infected with HIV, collaborating with their HIV/AIDS care providers to ensure these patients complete treatment for both conditions. She also travels each year to Swaziland in southern Africa -- the country with the highest prevalence of HIV in the world -- to treat patients with HIV-related opportunistic infections and to educate midwives there about the reproductive health of pregnant HIV-positive patients.
Cancer patterns among patients with HIV/AIDS have shifted significantly in recent years, according to a new study(jnci.oxfordjournals.org) from the NIH. In an April 11 news release(www.nih.gov), the agency said cancer types specifically associated with the progression of AIDS have decreased, while other types of cancers for which people with HIV infection are at increased risk are on the rise.
Kaposi sarcoma, non-Hodgkin lymphoma and invasive cervical cancer are among the criteria used to determine whether an HIV-infected person has developed AIDS. These AIDS-defining cancers have declined dramatically, from nearly 34,600 cases between 1991 and 1995 to about 10,300 cases between 2001 and 2005.
But people with HIV infection also are at increased risk for other types of cancers, known as non-AIDS-defining cancers. These include anal, lung and liver cancers, as well as Hodgkin lymphoma. The total number of these other cancers tripled, from about 3,200 during the 1991-95 period to slightly more than 10,000 during the 2001-05 period.
The NIH attributes the drop in AIDS-defining cancers to improved treatments for HIV/AIDS, including the introduction of highly active antiretroviral therapy that has improved immune function, reduced the risk of AIDS progression and improved survival for people with HIV infection. The increase in non-AIDS-defining cancers reflects a quadrupling of the number of people in the United States living with AIDS, especially those ages 40 and older, the agency said.
Her training to care for HIV/AIDS patients has been "self-directed and self-motivated," Curley said, explaining that she takes a number of CME classes provided by local and national organizations that focus on HIV/AIDS care updates and chronic disease management.
Family physician Ronald Labuguen, M.D., of Brisbane, Calif., also provides care for patients with HIV/AIDS, although he's quick to note that he has FP colleagues in the University of California, San Francisco, School of Medicine Department of Family and Community Medicine with "far more experience and expertise" in HIV/AIDS care.
According to Labuguen, who is an associate clinical professor in the school's family medicine department and a member of the AAFP Commission on Education, experience is key when it comes to treating this patient population. "You learn how best to care for HIV/AIDS patients by caring for HIV/AIDS patients," he told AAFP News Now.
"I don't think that one really needs any formal special training in order to care for these patients, but it does take a commitment to learn about the disease and stay abreast of developments," Labuguen said.
FPs have varying levels of comfort in providing care for patients with HIV, Labuguen added, just as they do for patients with other complex conditions. But, he said, "I do believe there is a basic level of knowledge that all family physicians should have in caring for these patients, and that they should be familiar with and have access to resources to address clinical situations with HIV patients when they encounter them."
Labuguen agreed with the IOM report's contention that most health care professionals receive little training and experience in HIV care, especially in outpatient settings. But that shouldn't handicap FPs who want to provide care for these patients, he insisted. HIV/AIDS care can be incorporated into FPs' residency training, and that foundation can be supplemented by attending conferences, reading and building a consultation network of HIV/AIDS experts.
Labuguen's own experience illustrates this point. Before moving to San Francisco four and one-half years ago, Labuguen said he had not encountered many patients with HIV infection.
"That changed when I took my current position," he said. "I'm blessed to have colleagues in my department who are experts in this field. I attend on our family medicine inpatient service and have learned a lot through that experience when we care for HIV/AIDS patients who have been admitted. I work also in the hospital's urgent care center and have learned fairly subtle ways in which HIV infection can present clinically.
"Family physicians can certainly provide this care, as long as they are properly motivated to learn and keep learning. You don't necessarily need to be fellowship-trained to be able to care for HIV/AIDS patients. But it's great to have those fellowship-trained specialist colleagues as part of your and your patients' team when you need them."