Thursday, May 5, 2011

HIV is essentially a chronic, treatable disease.

HIV Experts Recommend Shifting HIV Care To Primary Care Doctors

By Kieryn Graham 
Published: May 4, 2011 10:17 am

In a recent editorial, Dr. Mitchell Katz, a physician with extensive experience in treating patients with HIV and AIDS, argues that HIV/AIDS care should shift from HIV specialists to primary care physicians now that, in his opinion, HIV is essentially a chronic, treatable disease.  The editorial comes several weeks after an Institute of Medicine report warned of serious and growing shortages in the HIV healthcare system and also recommended shifting more HIV care to primary care doctors.
“If specialty care is less needed than it used to be for HIV-infected patients, it turns out that primary care is more needed. Owing to the advances in HIV treatment, our patients are no longer dying: they are aging!” wrote Dr. Katz, director of the Los Angeles Department of Health Services.
Dr. Katz argued in the editorial that HIV is now largely a chronic disease with relatively routine care that could be provided by primary care physicians, as is the case with diabetes.
Most people with HIV now begin treatment with Atripla (efavirenz/emtricitabine/tenofovir), a once-daily pill containing three antiretrovirals that has simplified HIV treatment. In addition, viral load testing – which measures the amount of HIV in the blood and allows physicians to measure how effective HV treatment is – has become fairly routine.

Dr. Katz argued that with the newer drugs and monitoring abilities, patients with effectively suppressed viruses are unlikely to develop the opportunistic diseases that made HIV treatment so difficult in the 1980s and 1990s.
“The most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is non-adherence, a primary care problem if ever there was one,” wrote Dr. Katz.
“The small percentage of patients who do not obtain a good response to a conventional regimen despite being adherent will need referral for specialty care,” he added.
Instead, the primary challenges faced by people with HIV are increasingly caused by other conditions, such as heart disease, bone loss, and other problems – issues which, according to Dr. Katz, are best dealt with by a primary care physician.
Primary Care Physicians May Fill In Gaps Left By Dwindling Numbers Of HIV Specialists
The Institute of Medicine (IOM) report, published last month, also recommended shifting more HIV care to primary care doctors, stating that decreasing numbers of HIV specialists, along with a growing HIV-positive population, are placing strains on the current United States healthcare system.
In addition, people with HIV are increasingly moving from urban centers to more rural areas where HIV-care providers are especially scarce.
The authors recommended that primary care physicians receive better training in caring for people with HIV and that medical students receive greater exposure to outpatient HIV care throughout school and post-graduate training.
Kathryn Hafford, a registered nurse and director of the Division of Disease Prevention of Virginia’s Department of Health, said in correspondence with the AIDS Beacon that fewer medical students are choosing to specialize in HIV care.
“The health care system is strained and does not have enough qualified providers to increase HIV testing and ensure availability of medical care. Older HIV physicians are leaving the field faster than new physicians are entering,” said Hafford, who was not involved with the report. “Physicians are often not choosing infectious diseases because they can make substantially more money in other specialties,” she added.
She agreed with the IOM that more training for primary care physicians is needed. “Providing increased awareness of HIV in curricula, as well as encouraging students to pursue primary care and HIV specialization could make a significant difference in the availability and quality of care,” she said.
“Faculty need to make sure students consider HIV when working with patients with other health issues because less media publicity, improved treatment regimens, and focus on HIV in developing countries have resulted in some people thinking HIV is no longer a problem in the U.S.,” she added.
The IOM report noted that 45 percent of HIV-positive individuals aged 15 to 49 years are eligible for antiretroviral therapy under current treatment guidelines but are not receiving it.
In addition, the introduction of the Patient Protection and Affordable Care Act and the accompanying elimination of certain eligibility requirements for Medicaid are likely to bring more people with HIV into the Medicaid program, increasing demand for HIV care.
Challenges Remain In Shifting HIV Care To Primary Physicians
A number of challenges remain before HIV care can be shifted to primary care physicians, including the fact there is also a growing shortage of primary care doctors. Providing more training in HIV care for students who plan to become primary care physicians may not be enough.
“With the cost of medical school so high, many students prefer to enter a specialty that will provide a higher salary,” said Hafford.
The IOM report noted that medical students face a financial disincentive to go into HIV care, with one physician in the report commenting that HIV physicians are relatively poorly paid and most HIV clinics would not be sustainable without government funding.
The authors of the report suggest financial and other incentives, such as loan forgiveness or scholarships, to encourage entry into HIV care. The report also advocates that Ryan White clinics, which provide HIV care but also broad range of medical and nonmedical services, serve as models for future care systems.
Paul Cleary, chair of the IOM’s Committee on HIV Screening and Access to Care, stated in correspondence with the AIDS Beacon that significant changes would be necessary to implement the recommendations in the report.
“We are at a very exciting juncture because of the release of the National AIDS strategy, but for the strategy to have a substantial impact we will need to address a wide array of regulatory and policy issues and make a concerted attempt to address the capacity issues described in the IOM’s report,” said Cleary.
“The Office of National AIDS Policy will develop responses and policies based on the information in the IOM’s report,” he added.
For more information, please see the editorial in the Archives of Internal Medicine (subscription required) or the IOM Report.

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