HIV and ID Observations

Earlier this year, I wrote a piece about friends and colleagues of mine who have left HIV clinical practice. Something about it touched a nerve. It’s one of the most commented-on pieces in the history of this blog.

Read this for a typical response.

Admittedly, it was kind of a downer — but it might have been slightly misinterpreted. A lot of the problems my friends cited could have easily applied to almost any area of clinical practice; these challenges were by no means limited to HIV care.

They mentioned the inscrutable and user-unfriendly EMRs, the lack of appreciation for cognitive specialties, the pain of “quality metrics” that require endless box-checking, the difficulties of funding care for the underserved. Safe to say that every primary care clinician in the country feels the same pain.

So, here’s a flip side to caring for patients with HIV, and it’s not just me resorting to the form that prompted my family to give me this T-shirt as a commentary on my sunny personality. I truly believe that HIV care remains an extraordinarily gratifying aspect of ID clinical practice. Which is why it’s critical that ID doctors continue to do it.

Here, in a bulleted list for clarity, are a bunch of things that make HIV care spectacularly rewarding:

• You can save someone’s life. Antiretroviral therapy is miraculous. Every ID/HIV specialist has had patients with advanced HIV disease and multiple complications literally rescued from the jaws of death by these lifesaving drugs. If you’re a clinician who doesn’t do surgery, it doesn’t get better than this, folks.
• You can really get to know your patients. You might be surprised given my youthful appearance (ha), but I’ve been doing this a long time. Fortunately, my career has included that breathtaking time in the mid-1990s, when suddenly we had effective HIV treatment. As a result, I’ve been following some of my patients for more than two decades. I know Brian’s favorite Dorchester restaurant since he moved from the South End, Felicia’s daughter’s name and what play she’ll be in this semester at college, Cliff’s excitement about this year’s Red Sox, how long Mark drives on his truck route each day, how Evelyn has never missed an episode of Grey’s Anatomy (there have only been 317), Ira’s struggles with his latest software release, and what vintage car Tony is working on in his shop. (And yes, I changed their names!)
• You will care for an extraordinarily diverse group of people. Despite stereotypes, there is no “typical” person with HIV, just like there’s no “typical” person with most infectious diseases. They will come from every race, occupation, country, and tax bracket. Our clinic cares for patients in their late teens up to their late 80s; our oldest patient just died of non-HIV-related causes shortly after her 90th birthday.
• You will continue to learn a lot about non-ID medicine. The aging of the HIV population forces us to keep up with all these interesting and common non-ID-related problems and issues — diabetes, hypertension, osteoporosis, atherosclerotic disease, cancer screening, neurocognitive decline, depression, venous thrombosis, chronic renal disease, atrial fibrillation. As a long-term patient of mine said to me the other day, “The HIV part is great. It’s all the rest of the stuff that I struggle with!”
• The field is constantly changing — for the better. Although almost all of the patients who regularly attend clinic visits are virologically suppressed, HIV treatment is always evolving — there’s a constant push to make what’s already great even better. That patient who was successfully treated in 1998 with d4T, 3TC, and indinavir, suffering through neuropathy, kidney stones, and ingrown toenails (yes, that was a complication of indinavir), may well be receiving a single pill with none of these side effects today. Ongoing research is pushing toward long-acting therapies (a once-weekly pill? a shot every 3 months?) — and, potentially, a cure. I wouldn’t bet against either eventually becoming a reality, though admittedly the cure part is still a ways off.
• The science of HIV prevention has never been stronger. As exciting as we find the information that people on suppressive HIV therapy cannot transmit the virus to others, imagine how this feels to our patients? It is wonderful giving them this news. It is both liberating and, just as important, helps diffuse some of the stigma that has stubbornly stuck to HIV ever since AIDS came on the scene in 1981. For people without HIV, pre-exposure prophylaxis (PrEP) is nearly as much of a game-changer. Will one of the HIV vaccines currently in clinical trials be the next advance?
• Your expertise will be valued in both the outpatient and inpatient setting. While most people with HIV are healthy and followed as outpatients, there is still a significant and important amount of care done in the hospital. These include patients with opportunistic infections and cancers, as well as non–ID-related issues that may influence HIV treatment selection. The mix of inpatient and outpatient care brings a wonderful diversity to the experience.

So, for you ID doctors out there, please keep doing HIV patient care — it remains among the best things I do as a clinician, and I don’t expect that ever to change.

Until we have a cure, that is!