to the editor: The article1 and editorial2 on care of patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in the January 15, 2006, issue of American Family Physician emphasized the important medical services that family physicians can provide for patients infected with HIV, including health care maintenance, baseline evaluation and laboratory studies, and monitoring to guide the initiation of antiretroviral therapy and prophylaxis against opportunistic infections.
The role of family physicians will need to shift toward routine HIV screening for nearly all of our patients. The Centers for Disease Control and Prevention (CDC) recently released new guidelines that recommend making HIV testing routine.3 The new federal guidelines will recommend one-time HIV testing for everyone between 13 and 64 years of age, with annual testing for those with risk factors. The new CDC guidelines are not consistent with those issued by the U.S. Preventive Services Task Force, which did not find enough evidence to recommend for or against routine HIV screening.4 The guidelines also are in conflict with some state HIV testing laws. Nevertheless, it is likely that routine testing for HIV will soon become the standard of care.
Family physicians will need to dedicate additional time to discussing various aspects of HIV testing with patients, nearly all of whom will not be infected. It will be important to explain to patients that HIV now will be considered a routine test, one that they may refuse (the so-called “opt-out” option). Physicians can expect a fair number of false-positive tests in low-prevalence populations and should advise their patients about this possibility. In addition, physicians will need to be able to clarify certain test results, such as indeterminate tests and the meaning of a positive rapid HIV test before confirmation.
Routine HIV screening will give family physicians more opportunities to impede the spread of HIV and impact its clinical course in infected patients. In addition to referral to local experts, up-to-the-minute telephone consultation is available to assist the busy family physician in this important role.
One resource for advice on testing and other clinical issues is the National HIV/AIDS Clinicians' Consultation Center (NCCC). Many family physicians use the NCCC hotlines as a source of HIV consultation in providing primary care for HIV. The NCCC, located in the University of California–San Francisco Department of Family and Community Medicine, has three free and confidential telephone consultation lines: (1) the National HIV Telephone Consultation Service (800-933-3413) offers assistance to all clinicians, from those with limited experience with HIV to those with complex antiretroviral resistance dilemmas; (2) the National Clinicians' Post-Exposure Prophylaxis Hotline (888-448-4911), which provides guidance in managing occupational exposures to HIV and hepatitis B and C; and (3) the National Perinatal HIV Consultation and Referral Service (888-448-8765), which provides advice on HIV testing and antiretroviral use in the prenatal, intra-partum, postpartum, and neonatal periods. In addition, there are 11 regional AIDS Education and Training Centers with more than 140 local sites that provide training and consultation for primary care clinicians nationally (http://www.aidsetc.org).