An ongoing dialogue on HIV/AIDS, infectious diseases,
November 20th, 2011
Who Should Care For The Aging HIV Patient? Everything Old is … Oh You Know
Over in Journal Watch AIDS Clinical Care, Carlos Del Rio reviews a couple of remarkable studies on HIV and aging. From one of them:
Compared with the controls, the HIV-infected patients had a higher prevalence of renal failure, bone fracture, and diabetes in every age range evaluated, as well as a higher prevalence of cardiovascular disease and hypertension at age 60… Of note, the HIV-infected patients appeared to develop polypathology at a younger age than controls, such that a 40-year-old HIV-infected patient had a risk similar to that of a 55-year-old HIV-uninfected person.
Wow, I bet that last fact gets quoted a lot.
Carlos concludes by suggesting “Now may be the time for many of us to take a refresher course in primary care for the HIV provider.”
A reasonable proposal — but one which prompted a reader to comment:
I fear this may reflect the common misperception that primary care is easier than disease specific care, especially with a disease like HIV… Perhaps we should focus on educating primary care doctors so that they feel more comfortable with HIV patients rather than HIV clinicians so that they feel more comfortable with primary care.
I completely agree — being an excellent primary care doctor has got to be one of the hardest jobs in all of medicine. I could never do it, which is why I chose to memorize all the cephalosporins, non-pathogenic intestinal protozoa, and the thymidine-associated mutations instead.
But what I find particularly interesting about this exchange is that it raises — again — the question about who should be caring for people with HIV. This has been an area of debate going way back to when the disease was first described, and the funny thing is that the perspectives keep flipping back and forth.
Back in the 1980s, it was argued that all PCPs should learn to manage common HIV-related complications because “the small number of subspecialists and other interested physicians now caring for most patients with AIDS will be overwhelmed” by the rapidly growing numbers of patients. Plus, some ID doctors (especially those spending the bulk of their time doing hospital-based consults) wanted little to do with a progressive, incurable infection that placed a premium on longitudinal outpatient and palliative care.
San Francisco was always a vanguard in the “HIV is a primary care disease” approach. In this paper from the 1990s, the authors state that the general medicine residents at UCSF rotated through the continuity HIV clinic, but the ID fellows didn’t. Amazing.
Then along came effective prevention and treatment strategies for opportunistic infections, followed by multiple advances in antiretroviral therapy, lipodystrophy, lactic acidosis, viral load monitoring, the mind-boggling complexity of resistance testing, the drug-drug interactions, and so on. With all that, HIV became the quintessential specialty disease. This was the pervasive view back in 2006, the last time we covered the topic in AIDS Clinical Care.
But today? The vast majority of people in care for HIV are virologically suppressed (especially true among those who show up for office visits), and they’re on stable HIV regimens — usually regimens that have been, and likely will remain, stable for years. That’s the good news.
Of course if you decrease deaths, you increase survival, and people get older, with older-people problems. We heard this summer at IAS that more than half the HIV population of San Francisco is now older than 50. One afternoon last week only one of the patients I saw was younger than 50, and she was 48.
(50. That’s positively ancient. Ha ha.)
All were virologically suppressed, rock-solid stable from the HIV perspective. I didn’t change a single HIV regimen, or do a single ID-related task that isn’t comfortably within the repertoire of a generalist.
So what did I do? Talked about PSA (pros/cons), bone density screening, lipid abnormalities, diabetes, various aches and pains — plus the struggles they are having with their aging parents, or the flip side, the joys of having grandchildren.
And if that sounds to you a lot like general primary care, you’re absolutely right.
So who should be providing the bulk of care for our aging HIV patients? ID/HIV specialists? Primary care providers? Some combination?
6 Responses to “Who Should Care For The Aging HIV Patient? Everything Old is … Oh You Know”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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As a recently retired primary care internist who chose to do HIV primary care as part of a General Internal Medicine practice, I have gone back and forth on this question. I now think we should have interested primary care providers (including mid-level practitioners) doing HIV care with back up from ID trained specialists. The key is finding providers who enjoy HIV care and see enough HIV patients that they are motivated to keep up in the field. In most of the ID specialist practices that I’m familiar with, NPs and PAs provide a lot of the day to day care and the docs back them up. And they provide excellent care. The key is how to recruit enough MDs and DOs with or without ID training as well as mid-levels to meet demand. Our residents and students are getting seduced away by the hospitalist programs. There’s the major problem and it is all about money.
I think HIV/AIDS can be treated in primary care in a similar way to other conditions for which patients periodically see specialists; when their disease process is stable or improving, returning to the specialists at the interval recommended by specialists, or when their disease is progressing and requires reassessment of their medication regimen.
As an HIV Specialist who is also a Family Physician, I am biased towards both worlds of HIV and primary care.
HIV by its nature of involving the whole body, the psyche, the family, and society has required such attention from HIV practitioners no matter their initial training. ID Physicians who have been doing HIV care over a long period of time appear a lot more primary care minded, if you will, and more aware of multiple interacting medical conditions, social issues affecting health and the diseases of the mind.
Primary care training is geared at onset to contemplate a complex and interacting image of the patient’s various medical, social, and psychiatric issues. HIV care, with its multi-organ, multi-disease, psycho-socially involved nature fits into this primary care model easily.
The most basic part of a primary care practitioner’s training is to know when he/she does not know something, and when to ask and consult a colleague. Having access to an HIV-savvy clinican should make it possible for all primary care clinicians to do a good job of caring for HIV infected patients.
Message:
1) Encourage more HIV training in Primary Care (via American Academy of HIV Medicine for example) so more can feel comfortable caring for HIV + patients and help their colleagues who are less familiar with HIV.
2) Get more primary care training for interested ID docs keeping in mind that some may have no interest in this, in which case they should collaborate with a primary care clinician they work closely with.
3) The job cannot be done without some merging of primary care and HIV knowledge.
I think it is interesting to look back at the history of HIV care in this country. As a primary care internist in New York City, I became involved in the treatment of many early HIV patients circa 1981, as were many primary care physicians who happened to have a large panel of MSM patients. Just as we all developed expertise in the treatment of STD’s, including the so-called “gay bowel syndrome”, our knowledge of the new immunodeficiency syndrome evolved as we saw our first cases of pneumocystis and KS. Now, unfortunately, it appears that HIV care has been co-opted by ID specialists and is not adequately incorporated into the training of many general internists. Clearly, with many of our patients successfully aging with HIV, there is an even stronger need for “history to repeat” and more primary care docs, well-versed in cardiovascular and geriatric disorders, among others, to get back into the field. Management of HIV meds should also be taught and “demystified” in all general internal medicine programs.
Why limit this discussion to HIV clinicians V Primary Care providers?
Aging HIV patients can be cared for by care of elderly team, end of life/hospice team both inpatient and community services. Essentially everyone lives within a community and belows to a primary care setting for their general health needs, so it seems obvious to me that as the aging HIV patient will be cared for in the community there MUST be primary care input with specialist support from HIV clinicians, just as there is with other health needs.
Primary care physician can take part in Chemoprophylaxis, OI Management of
HIV Disease, if not in ART. OI management is more or less same as that of
any infectious disease management. Only thing is a better understanding
about this disease and there must be some interest in treating the HIV
infected people.