Unlike other diseases in the modern era of medicine, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) have followed a tumultuous and unpredictable path, for doctors and patients alike. Since the first five cases of pneumocystis pneumonia were reported in 1981, patients with HIV/AIDS have found themselves passed back and forth between subspecialists and family physicians. With every treatment advance, infectious diseases specialists took over the care of patients with HIV/AIDS to manage complex treatment regimens; with every setback registered by disappointing mortality outcomes, family physicians would again assume primary responsibility for these patients, focusing on health maintenance and palliative care. Now that we are almost 25 years into the epidemic, HIV/AIDS has become, as Dr. Khalsa1 points out in this issue of American Family Physician, “a chronic, manageable disease,” perhaps not unlike diabetes, hypertension, or hyperlipidemia. Unlike these conditions, AIDS is a contagious, infectious disease, that if left untreated, almost invariably leads to death within eight to 10 years. It is a disease whose control depends on potent antiviral medications and whose natural history will not be affected significantly by dietary or lifestyle changes.
Should family physicians be providing all the medical care for patients with HIV/AIDS? The article1 by Dr. Khalsa does an excellent job of pointing out the needs of patients living with this disease. Moreover, the Infectious Diseases Society of America recently published clinical guidelines for the “primary care” of patients with HIV.2 Included are the baseline evaluations for a newly diagnosed patient as well as required screening tests and immunizations. All are certainly within the scope of the family physician, and recent data show that generalist physicians with HIV expertise provide care of similar quality to that of infectious diseases subspecialists.3
As a family physician providing HIV care since 1989, I would be hypocritical in suggesting that family physicians should not be caring for patients with HIV. I also have a marked appreciation of the depth and breadth of information we have regarding HIV/AIDS. Currently, 20 drugs are available to treat HIV. Although guidelines for their use exist, decisions about treatment are complex.4,5 These include the decision to start antiretroviral therapy as well as the selection of a specific regimen. What follows is long-term monitoring for efficacy, compliance, adverse events, and resistance. In many cases, based on toxicity or new clinical trial data, a patient’s antiretroviral regimen must be changed one or more times. These are issues most family physicians will not have the training, time, clinical experience, or desire to cope with.
I encourage family physicians caring for patients with HIV to establish a close partnership with the patient and HIV subspecialist. This individual can manage the antiretroviral therapy but depends on the family physician to provide the comprehensive long-term care that the patient with HIV/AIDS needs. Because more than 40,000 people are infected each year, and because those with the disease are living longer, there will be a growing need for more physicians to assume the primary and specialty care of these patients. About one half of the HIV subspecialist in the United States have been trained in family or internal medicine. For those wanting to provide HIV specialty care, excellent training and educational resources are available through the American Academy of HIV Medicine (http://www.aahivm.org).
Family physicians who choose not to pursue specialized training in HIV care can still make an enormous difference in health outcomes of patients with the disease by providing universal HIV screening, prevention and risk reduction counseling, basic monitoring, and regular maintenance care. The recommendation for all patients to undergo one-time HIV screening is well supported by two recent studies.6,7
In addition, the U.S. Preventive Services Task Force updated its testing guidelines, and although not recommending universal testing, it called for an expansion of existing protocols for HIV screening and reemphasized the need to screen adolescents and adults with any HIV risk factors and all prenatal patients.8
In addition to counseling about testing, risk reduction, and partner notification, family physicians can monitor disease progression by disease state or CD4+ count and participate in determining the patient’s candidacy for antiretroviral medications. Finally, family physicians should be aware of any recommended screening tests, immunizations, and prophylaxis. In the years ahead, when it is hoped that we will have an effective vaccine, the family physician will continue to play a key role in caring for these patients.