HIV Infection/AIDS

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

The ultimate concern of all physicians is the welfare of the patient. The patient's age, background or illness may call for different approaches to care, but appropriate history and physical examination skills and the social and psychologic aspects of care must be integral parts of physician training.

The pandemic of human immunodeficiency virus (HIV) infection is a vital concern to family physicians. Family Physicians are well suited to help prevent persons from becoming infected and to care for those who are infected. Because the basic tenets of family practice emphasize a compassionate, whole-person approach to patient care, the application of specific knowledge and skill for a wide variety of disease entities, and a comprehensive and continuous commitment to patients and their families, family physicians have an important role to play in the care of HIV-infected individuals. In addition, the diverse population served by family physicians provides a unique opportunity for patient education and prevention. Family physicians should be knowledgeable about the multiple issues related to the care of patients with HIV disease and the acquired immunodeficiency syndrome (AIDS) and must develop skills to stay abreast of new developments in the treatment of patients with HIV infection.

These curriculum guidelines are intended to assist in the development of an HIV/AIDS curriculum for family practice residencies. Because the knowledge base and technology related to HIV/AIDS are rapidly changing, family physicians must also be aware of the resources available to maintain updated information and skills.

Attitudes

The resident should develop attitudes that encompass:
An awareness of the importance of the physician's own attitudes toward sexuality, intravenous drug abuse, cultural differences, communicable diseases and death
An understanding of the importance of quality-of-life issues
The necessity for compassion and objectivity when dealing with patients who have a chronic and potentially life-threatening illness
Recognition of the physician's abilities and need for further consultation
A willingness to function in the role of coordinator of medical and non-medical services
Recognition of the importance of support from family members and others
Acceptance of the physician's continuing responsibility to support the patient and family throughout all stages of the illness
An awareness of the importance of setting a positive example for other health care providers and the community
The willingness to obtain sexual and drug histories from patients that are appropriate to their medical care needs
An awareness of community and cultural attitudes toward the illness and the need for confidentiality

Knowledge

General considerations
1. Scientific background
  1. HIV virology and pathophysiology
  2. Immunodeficiency manifestations and complications
  3. Epidemiology
    1. Modes of transmission
      1. Sexual intercourse
      2. Intravenous drug use
      3. Vertical transmission from mother to child (e.g., intrauterine, intrapartum, postpartum, breast feeding)
      4. Other exposure to human body fluids (e.g., blood and blood products, needlesticks, etc., including transmission in the health care setting)
2. Definitions
  1. Centers for Disease Control (CDC) surveillance case definitions for AIDS
  2. Diagnostic categories: HIV positive asymptomatic; HIV positive symptomatic; AIDS
3. Laboratory testing
  1. Type of test
    1. Antibody: ELISA (enzyme-linked immunosorbent assay)
    2. Confirmatory tests: Western blot, immunoflorescent antibody
    3. CD4 + lymphocyte counts
    4. Viral load
    5. Resistance testing
  2. Indications for testing
    1. Risk assessment and recommendations for voluntary testing
    2. Clinical assessment
    3. Public health surveillance
    4. Mandatory testing regulations
  3. Test results and counseling
    1. Appropriate pre- and post-test counseling
    2. Confidentiality issues
    3. Public health case reporting
    4. Mandatory reporting regulations
    5. Partner notification
Clinical manifestations
1. Opportunistic infections: candidiasis; Pneumocystis carinii pneumonia; cryptococcosis (extrapulmonary); cryptosporidiosis; cytomegalovirus infections; herpes simplex and herpes zoster, Mycobacterium avium complex, M. kansasii infections and m. tuberculosis infections; toxoplasmosis
2. Associated malignancies: (eg, Kaposi'sarcoma and lymphoma)
3. Other HIV syndromes: progressive multifocal encephalopathy, HIV encephalopathy, dementia, HIV wasting syndrome
4. Special presentations of children: failure to thrive, abnormal milestones
5. Special presentations of pregnant and nonpregnant women: cervical cancer, cervical and vulvar/vaginal dysplasia, vaginal fungal infections
6. Hepatitis B and C
Treatment and patient-care issues
1. Pharmacologic management
  1. When to initiate antiretroviral therapy
  2. Antiretroviral drug categories
  3. First-line regimens
  4. Monitoring effectiveness of regimen
  5. Assessing side effects
  6. Drug-drug interactions
  7. Defining treatment failure
  8. Selecting alternative regimens
  9. Assessing adherence
  10. Pharmaceutical resistance
2. Knowledge of the range and limitations of services available both in ambulatory and inpatient care
3. Characteristics of rehabilitation, long-term and alternative care, and housing
4. Collaboration with consultants
5. Availability of experimental treatments
6. Health care maintenance and immunizations
7. Prophylaxis against common opportunistic infections and when prophylaxis can be discontinued
8. Treatment options during pregnancy
Psychosocial and ethical issues
1. Physician responsibility and patient abandonment
2. Death and dying
3. "Do not resuscitate" (DNR) orders
4. Rights of the individual versus rights of society
5. Confidentiality and record keeping
6. Intravenous drug use
7. Sexual practices
8. Patient competence determination, conservatorship and durable power of attorney
9. Family resources and family contributions
10. Impact on the family
Legal issues
1. Confidentiality of medical records
2. Occupational Health and Safety Administration (OSHA), Department of Health and Human Services (DHHS) requirements
3. Federal requirements
4. Local laws
5. Testing by employers and health insurers
Financial considerations
1. Eligibility criteria for Medicare, Medicaid and Social Security
2. Available funding for health care and medications
Special considerations for health care providers
1. Occupational risks and prevention strategies
2. Specific psychosocial and ethical issues
3. Impairment and work-related disability
4. Post-exposure prophylactic treatment protocol and recommendations

Skills

The resident should develop skills that encompass the ability to:

Evaluate
1. Take sexual and drug histories and perform risk factor assessment
2. Perform a comprehensive physical examination
3. Select appropriate diagnostic procedures
4. Interpret the results of HIV testing
5. Set appropriate priorities for investigation with patient, family and friends
6. Investigate common symptoms (fever, cough, diarrhea)
7. Recognize life-threatening situations (e.g., severe hypoxia, cytomegalovirus retinitis, drug overdose)
8. Know how to perform or when to refer for screening (e.g. PPD, cytomegalovirus)
Prevent
1. Provide health education and preventive counseling
2. Counsel HIV-positive individuals and contacts regarding risk of virus transmission
3. Consult with community groups and lead group discussions about risks of transmission
4. Perform prenatal testing and counseling in high-risk groups
5. Be informed about and comply with institutional protocols for the protection of employees
Manage
1. Formulate a problem list and prioritize a management plan
2. Provide antiretroviral therapy
3. Utilize and coordinate multiple consultants and resources
4. Coordinate ambulatory, inpatient and long-term care
5. Counsel patients and significant others appropriately about testing and test results, therapeutic modalities and prognosis
6. Provide competent terminal care
7. Manage HIV exposure in the work environment
Community involvement
1. Interact with and assume leadership in medical, social and political communities
2. Provide education about HIV infection and AIDS in medical, social and political settings
Use on-line and Internet resources to obtain current protocol guidelines Implementation

The implementation of these curriculum guidelines is best achieved within the capabilities of the residency program, using outside resources when necessary. Residents should have basic knowledge and skills to care appropriately for their own patients as well as to be a community resource for information about HIV issues. Any training effort must also strive to maintain an up-to-date curriculum that includes recent advances.

Precise details of implementation will vary among residency programs, depending on interest levels and the amount of contact with HIV-positive patients.

Resources

National AIDS Information Clearinghouse
Sponsored by the Centers for Disease Control, this Clearinghouse is a comprehensive information source for those involved in AIDS education. Information is available on more than 6,000 programs, projects, and organizations providing AIDS-related services.
800-458-5231
9 a.m. - 6 p.m. Eastern Time
Monday-Friday

National HIV Telephone Consultation Service (Warmline)
Sponsored by the Health Resources and Services Administration (HRSA) and the AAFP, this service provides clinicians with information and case consultation for HIV/ AIDS management
800-933-3413
10:30 a.m. - 8 p.m. Eastern Time
Monday-Friday

Web Sites:

http://www.aidsinfo.nih.gov/

http://hivinsite.ucsf.edu/

http://www.cdc.gov/

http://www.ama-assn.org/

http://www.aafp.org/

Published 12/88
Revised 10/91
Revised 6/99
Revised 12/01