This was successfully posted to your pofile.
This box will close automatically in a few seconds. Close this window
We don't have an e-mail address on file for you. To use AAFP Connection, you must have an e-mail address in our records. Click Here
Targeted Training, Education Can Help FPs Stay on Top of Testing for, Managing HIV/AIDS
By Barbara Bein
"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.
Academy Offers Guidance on HIV Screening, Treatment
The 2007 policy also notes that medical schools and family medicine residencies should ensure that medical students and residents are educated about appropriate blood and body fluid precautions and have protocols in place to reduce exposure risk. Furthermore, the policy encourages FPs to participate in CME that enhances their knowledge about caring for people who are HIV-positive.
Finally, the policy offers guidance on prevention strategies and HIV testing, including which patient groups are at particular risk for the disease, as well as a discussion of the AAFP's stance on treatment for patients with HIV infection or AIDS.
The Academy's specific clinical recommendations regarding screening for HIV in different patient groups align with those issued by the U.S. Preventive Services Task Force in 2005 and, thus, differ from the CDC's 2006 recommendation to screen all people ages 13-64 who are seen in a health care setting. The AAFP makes no recommendation for or against routine HIV screening in adolescents and adults who are not at increased risk for HIV infection.
- 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.
Rapid Changes in Management Strategies
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.
"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.
Types of Cancer Affecting Patients With HIV Changing
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.
Commitment to Learning Needed
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."
FDA Adds Cardiac Warning to HIV Drug's Label
Combination of Saquinavir, Ritonavir Can Lead to Abnormal Heart Rhythm
More From AAFP
Residency Program Solutions: Recommended Curriculum Guidelines on HIV Infection/AIDS
(9-page PDF; About PDFs)