Medicine and Society
The Changing Spectrum of HIV Care
Am Fam Physician. 1999 Feb 1;59(3):545-548.
Remarkable advances in the ability to treat persons living with human immunodeficiency virus (HIV) infection have occurred in the past two years. The availability of viral load monitoring and a larger palette of antiretroviral medications have made a substantive impact on morbidity and mortality in persons with HIV. The new therapies and successful prevention efforts have been credited with a decrease in the overall incidence of acquired immunodeficiency syndrome (AIDS) and death.
A 23 percent decline in deaths associated with AIDS was noted between 1995 and 1996. Cases of perinatally acquired AIDS have been on a steady decline since 1993, primarily because of antiretroviral prophylaxis administered to women during the second and third trimesters of pregnancy and to the newborn. Unfortunately, AIDS case rates in adult blacks, Hispanics, heterosexuals and women continue to increase.
These trends serve as powerful reminders for family physicians to continue to broaden their scope of HIV-risk assessment and intervention. The White House National AIDS Strategy, issued in 1997, emphasizes multiple goals toward ending the HIV/AIDS epidemic,1 all of which are relevant to the family physician. The strategy includes the following goals:
Reducing the number of new HIV infections in adults and children in the United States by providing strong, continuing support for effective HIV prevention efforts.
Ensuring that all persons living with HIV infection have access to health care, housing and supportive services that are affordable, of high quality and responsive to their needs.
Ensuring that all persons living with HIV infection are not subject to discrimination.
Offering HIV counseling and testing to pregnant women—and antiretroviral treatment to those who desire it—to realize the promise of reducing perinatal transmission of HIV infection.
The strategy also emphasizes the need for better integration of HIV prevention into primary health care via improved sexual history-taking, offers of HIV counseling and testing, and provision of HIV education to HIV-infected persons.
With the increased complexity of antiretroviral treatment, medical communities are struggling with the question of who should provide care for HIV-infected persons.2,3 Studies linking lowered HIV mortality to greater physician experience fuel the debate,4 shifting discussions from a specialist versus generalist focus to patient volume-outcome issues. Family physicians, who have been on the frontlines of HIV care since the beginning of the epidemic, remain uniquely positioned to meet the challenges of HIV clinical care. Some family physicians continue to care for large panels of HIV patients, while others care for smaller numbers. Many persons become infected in urban settings and subsequently return to rural areas where family physicians and other primary care physicians without extensive HIV experience may be the only physicians available.5
New antiretroviral treatment guidelines help health care professionals stay abreast of this rapidly changing field.6 Viral load and CD4+ lymphocyte measurements are critical components in assessing prognosis and therapeutic effectiveness. Informing the patient of potential drug toxicities, side effects and the risk of future viral resistance is also critical. Yet the new treatments, when translated from clinical trials to real life, do not guarantee improved health to all, and treatment failures have become increasingly common over time.
The new drug regimens place the issue of patient adherence on center stage. To secure maximum benefit from treatment and to minimize the development of drug-resistant HIV strains (which can preclude the use of further therapies), the drugs must be taken regularly and without interruption. Some patients may not have the ability to follow these demanding regimens, but assessing such ability is complicated. Assessments cannot be made solely on the basis of patient characteristics, because the accuracy of such predictions is no better than chance.7 Improving adherence to therapy requires a joint effort by the patient and the physician, including simplifying complex drug regimens, adapting a regimen to the patient's lifestyle, educating and motivating the patient, reinforcing patient skills, problem-solving with the patient and collaborating with other providers.
Medicaid and Medicare will continue to be an essential component of health care support for disadvantaged populations as they experience an increasing burden of the HIV epidemic. The lifetime cost for treating a patient with HIV infection has been estimated to be $133,500, over 8.3 years of life.8 With newer antiretroviral strategies, these costs could be considerably higher, but the value of lives saved cannot be measured.
Another key financing source, the state-administered AIDS Drug Assistance Program (ADAP), is funded by Ryan White Title II monies to provide prescription drugs to those who otherwise cannot afford them. With the annual cost of combination anti-retroviral therapy and monitoring exceeding $10,000,9 ADAP programs face severe financial pressures in many states, especially with increased demand for new drugs. In 1997, four state ADAP programs did not cover protease inhibitors.
Because of the success of combination therapy, some patients now face a new dilemma—the prospect of returning to work—with profound legal, economic and psychologic implications. Many patients who were previously considered disabled under the Americans with Disabilities Act (ADA) and eligible for disability benefits may have sold their life insurance policies, spent to the limits of their credit accounts, cashed in retirement plans, and “spent down” life savings. They now face a possible loss of benefits and the need to pay off debts while reentering a changed job market, despite a still uncertain life expectancy. Primary care physicians can help these patients by understanding the issues involved and linking them to HIV support organizations.
What policy issues will affect family physicians in the near future? Three principal—and contentious—issues remain: HIV reporting, needle exchange, and postexposure prophylaxis. Proposed federal legislation would expand AIDS reporting to include HIV infection, implement a partner notification system, mandate HIV testing for indicted sex offenders and allow physicians to test patients without their consent before performing invasive procedures. Supporters of the bill argue that these measures are necessary to track and stem the epidemic and inform infected persons of their serostatus. Opponents contend that mandatory testing, reporting and notification deter people from getting tested and receiving care.
Whether testing is voluntary or mandatory, primary care physicians must improve their risk assessment skills as HIV infection continues to spread across risk groups and geographic regions. Research suggests that primary care physicians do not routinely perform risk assessment for HIV infection, often miss clinically important risk behaviors and can fail to include HIV infection in the differential diagnosis.10 These are serious shortcomings in light of recent estimates that as many as one-third of all HIV-infected persons remain undiagnosed.11
Providing clean needles and syringes to injecting drug users to slow the spread of HIV infection is a politically and emotionally charged issue, despite studies that have shown such programs to be effective in reducing HIV transmission.12 Attempts to secure federal funding for needle exchange programs have been unsuccessful—leaving state and local governments to finance the activity.
The use of postexposure prophylaxis after sexual or injection-drug exposures has become a topic of great debate. Prophylaxis has been recommended for exposures that occur in isolation, involve a person who intends to stop engaging in high-risk behavior, or when it is offered in the context of a comprehensive prevention program.13 Concerns about nonoccupational exposure prophylaxis include the fear that its availability might encourage unsafe behaviors and produce more drug-resistant strains of HIV.
The evolution of HIV management creates special challenges for primary care clinicians. Providing primary HIV care, including antiretroviral treatment, risk assessment and prevention, within the changing practice environment while maintaining personal care relationships with patients and their families will ultimately be the measure of excellence.
From the Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, and the Family Practice Residency Program at San Francisco General Hospital.
Supported in part by the Pacific AIDS Education and Training Center, Grant No. 2 U69PE00118-05 with the HIV/AIDS Bureau, Health Resources and Services Administration, Department of Health and Human Services.
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11. Sweeney PA, Fleming PL, Karon JM, Ward JM. A minimum estimate of the number of living HIV infected persons confidentially tested in the United States (Abstract I-16). Abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, Sept 28–Oct 1, 1997. Washington, D.C.: American Society for Microbiology, 1997.
12. Gostin LO, Lazzarini Z, Jones TS, Flaherty K. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users. JAMA. 1997;277:53–62.
13. Katz MH, Gerberding JL. The care of persons with recent sexual exposure to HIV. Ann Intern Med. 1998;128:306–12.
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