American College of Physicians: Internal Medicine — Doctors for Adults ®


Caring for AIDS patients: not just medicine as usual

From the September 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

Just six years ago, when Margot B. Kushel, ACP-ASIM Associate, was in medical school, AIDS treatment was much simpler. The inpatients she saw at that time, recalled Dr. Kushel, who is now chief resident at San Francisco General Hospital, were typically in the last stages of the disease. Medications had been stopped, and residents focused almost exclusively on fighting opportunistic infections.

With the recent explosion of life-prolonging AIDS drugs, treatment now emphasizes drug regimens that keep many AIDS patients out of the hospital. While residents still treat AIDS on an inpatient basis, they find they are often caring for individuals who don't really represent the overall HIV population.

Related Article:
  • Why too many are dying at the altar of privacy (March 1999) "We see the sickest AIDS patients first," said Kristin M. Burkart, ACP-ASIM Associate, a third-year resident at the University of Colorado. "Only later, when we rotate through the clinic setting, do we see patients taking their medications and living life to the fullest. At that point, we deal less with infections and more with drug therapies."

While the growth of life-prolonging drugs clearly benefits AIDS patients, it has limited training opportunities for residents who spend much of their time in the hospital. As a result, experts say that residents interested in AIDS care should rotate through an HIV clinic or, even better, work in a continuity clinic.

"Continuously caring for AIDS patients during my three years of residency made the difference for me," said Mari M. Kitahata, ACP-ASIM Member, who is now director of health services research at the University of Washington Center for AIDS Research. "It helped me tremendously in my practice." The experience not only exposed her to the latest therapies, but also helped her better understand the psychological needs of AIDS patients.

Here are some other tips to help you better care for your patients with AIDS:

Know the basics. "All residents should have a good understanding of the HIV classification scheme," said John V. L. Sheffield, ACP-ASIM Member, assistant professor of medicine at the University of Washington. Other basics include knowing the natural history of the patient's infection; understanding how the CD4 count can be used to assess risk; knowing how viral load testing can be used to guide therapy; identifying individuals at risk for rapid disease progression; and understanding the indications for opportunistic prophylaxis.

Identify HIV early. According to Dr. Sheffield, physicians do a poor job of early identification. Early signs such as mononucleosis-like illness, a possible symptom of acute antiretroviral syndrome, can be missed or incorrectly attributed to another condition.

To diagnose early infection, you must first suspect that the patient has recently been exposed, which makes taking a thorough history critical. "Doctors need to include HIV in the differential diagnosis, ask about HIV risk factors and consider testing patients who present with mononucleosis-like illnesses," Dr. Sheffield said.

Whereas the HIV antibody test is negative during acute HIV infection, viral tests will be positive. Detecting HIV early on is critical, explained Lisa G. Kaplowitz, FACP, director of the HIV/AIDS Center at Virginia Commonwealth University, because antiretroviral treatment during acute infection is beneficial and offers the best opportunity to maintain normal immune function.

Think "zebras." Retrain your brain to consider a "zebra" diagnosis, said the University of Colorado's Dr. Burkart. After you have considered the 10 most common complications or opportunistic infections, remember that there are probably another 10 to 20 less obvious causes that may be likely.

Prescribe adequately. Don't treat patients with a single antiretroviral agent. Dr. Kaplowitz said that in most cases at least three antiretroviral drugs are needed. That means residents need to consider drug interactions and multiple toxicities.

Help patients with compliance. Filling pillboxes during visits helps ensure that patients stick with their therapy. Having your patients complete a dry run with a placebo pillbox for a week or two before beginning a drug regimen also may help increase compliance. You also could advise patients to use a drug calendar or set up some other type of reminder system, said David L. Cohn, FACP, co-director of the infectious diseases/AIDS clinic at the Denver Health Medical Center. Sending personal letters to patients who miss an appointment often brings them back into the office for assessment.

Know when to refer. Know your limitations when it comes to diagnosing and treating AIDS patients presenting with complications such as pneumonias and central nervous system problems. "Don't just give the patient three drugs and say, 'I'll see you in six months,'" said Dr. Cohn. "Instead, explain the option of accessing experts in your geographic area."

Work with the team. To treat the spectrum of clinical and social issues surrounding AIDS, try using the team approach, which brings together mental health providers, social workers and clinician specialists. The entire health care team must work together to support patients with HIV and optimize their chances of remaining on antiretroviral therapy. Residents often say that working on such teams is one of the greatest rewards of caring for HIV patients.

Keep abreast of the literature. Use the Internet to keep up on the vast, fast-changing literature on AIDS. Guidelines for retroviral treatment are updated monthly, said Virginia Commonwealth University's Dr. Kaplowitz.

Get more training. If you feel you need more experience to handle the complexities of current AIDS diagnosis and treatment, augment your training through the AIDS Education and Training Center Program (AETC), which was developed by the government for practicing providers.

Through its network of 15 regional centers and associated sites, AETC offers training programs that range from a few days to several weeks. You may be able to arrange the training through your own residency program. (For more information, contact Juanita Koziol, Health Resources and Services Administration, 301-443-6364.)

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

HIV testing: delivering the news

One of the most stressful aspects of caring for HIV-infected patients is communicating test results. Rapid HIV tests pose an additional challenge because they require a same-day confirmatory test whose results will not be available for one to two weeks. Residents who will be communicating results of rapid HIV tests to their patients should consider the following:

When test results are negative. This is a good time to review the protective behaviors that have helped the patient avoid HIV transmission. Point out that the negative results may not be reliable if the patient has engaged in unsafe sex since the test or during the 25 days prior to the test. Explain that it takes 25 days for HIV antibodies to be detected following infection.

When test results are positive. Use a simple phrase to inform patients of their HIV status, such as, "Your first reactive test came back positive." Then explain the meaning of the test and the necessity for a confirmatory test. Emphasize that patients should adopt preventive behavior until their HIV status is confirmed.

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