HIV/AIDS: Is it time for universal screening?
From the June ACP Observer, copyright © 2005 by the American College of Physicians.
By Deborah Gesensway
SAN FRANCISCO—Considering how effective HIV antiretroviral therapy has become, and how much longer patients can live if they start regimens early, one of the nation's experts on HIV care now recommends that internists consider screening all their patients—even senior citizens—for the disease.
"We are not doing a very good job of diagnosing them early," College Regent Merle A. Sande, MACP, told attendees at an Annual Session course on HIV-infection issues for internists. Dr. Sande, who is professor and internal medicine program director at the University of Utah in Salt Lake City, is also president of the Academic Alliance Foundation for AIDS Care and Prevention in Africa, a program that brings North American HIV/AIDS experts to care for patients in Uganda. Dr. Sande said only 7% of acute HIV patients in the United States are correctly diagnosed during their first clinic visit.
According to Merle A. Sande, MACP, almost one-third of HIV-positive Americans do not know they are infected.
And HIV experts have learned how important it is to start antiretroviral treatment before CD4 counts get too low (greater than 200). If counts are allowed to drop too low and patients end up with a higher "viral set point" following the first acute HIV infection, they are likely to have a worse long-term prognosis.
"The set point determines how long you will remain asymptomatic," Dr. Sande said.
The case for universal screening
Dr. Sande argues for universal voluntary screening not only because effective treatments are now available but also because the medical community is learning more about HIV's prevalence. In this country, the overall incidence is 0.5% of the population. But health officials claim that about 30% of the 950,000 Americans who are HIV-positive do not know it.
Acute HIV should be considered in any patient who presents with a mononucleosis-like syndrome with symptoms of sore throat, malaise, fatigue, lethargy, low grade fever and anorexia. These patients typically have pharyngitis with enlarged tonsils, adenopathy or (in about 50%) a nonspecific macular-papular rash, particularly over the trunk.
While many may have atypical lymphocytosis, the Monospot and Heterophile tests will be negative. While the diagnosis is more likely to come to mind in a patient with high risk behavior, it should be considered in all persons presenting with this mononucleosis-like syndrome, but with negative diagnostic tests for mononucleosis.
The diagnosis can be established with a P24 antigen test or an HIV viral load test. It is important to remember that false positives may occur, particularly if the viral load is low, in the 3,000 to 5,000 range. Typically the viral loads will be in the 100,000 to 1 million level per millimeter-cubed range. The antibody tests to HIV (ELISA and Western Blot) will typically be negative early in the infection and prior to seroconversion.
"Acute HIV may account for 60%-80% of all transmission," he said. "That's worth remembering" when internists consider what to recommend to frightened patients who think they may have been exposed.
To recommend the correct post-exposure prophylaxis, internists faced with worried patients need to understand what the medical community now knows about transmission.
"You want to find out about the source patient," Dr. Sande said. If the person suspected of passing the virus along has HIV but is not in the acute phase or in end-stage AIDS, it is significantly less likely that the source patient transmitted the disease.
Knowing what drug regimen that source patient may be on is helpful too, because it can give physicians clues about which prophylactic therapy to recommend—and it can answer concerns about resistance.
Doctors should also make recommendations about prophylaxis depending on what they learn about the method of suspected transmission. A hollow-bore needle stick, for example, is more likely to transmit HIV than a stick with any other type of needle, such as a suture needle. The Jan. 21, 2005, Morbidity and Mortality Weekly Report contains the Centers for Disease Control and Prevention's updated antiretroviral postexposure prophylaxis recommendations.
Managing a chronic disease
Internists also need to learn more about long-term HIV/AIDS care. Dr. Sande predicted that in the not-so-distant future, the care of patients living for decades with the disease will become the bailiwick of general internal medicine.
"In the West, HIV is becoming a chronic disease like diabetes," he said. And just like taking care of diabetic patients, physicians need to figure out ways to improve patient compliance with long-term HIV antiretroviral treatments and to understand those therapies' complications. (For a look at changes in AIDS' diagnoses, see "AIDS diagnoses."
Studies of HIV patients in the United States have found that they take only between 60% and 80% of prescribed medications, while evidence shows they need to take nearly all of them to derive the maximum possible benefits, he said.
Adherence will likely improve when clinicians eventually reduce the number of daily pills that patients take. In Dr. Sande's Ugandan clinic, for instance, patients take fewer daily drugs than patients do here, where most patients currently follow a triple drug regimen that requires taking one pill two times a day.
"One pill once a day is better," Dr. Sande said. "We have that to look forward to."
Another important factor is managing the complications of therapy, particularly because the drugs now prolonging life can be "extremely toxic."
For example, he said, protease inhibitor-type drugs and non-nucleoside reverse transcriptase inhibitors can have a different effect on the hypercholesterolemia that some patients develop. Doctors are now learning, he said, that HIV/AIDS patients who develop lipid disorders or insulin resistance must be managed like other patients with those problems, taking into account the difficulty of adding more drugs to an already complicated regimen.
Internists also need to be aware that many HIV-positive patients are also infected with hepatitis C—and they may be depressed.
Because of complicated regimens, specialists have provided HIV care over the past decade, with the best care probably coming from those who work with teams that include clinical pharmacists and counselors. The team approach will likely continue to be optimal, with an added role for internists providing chronic HIV care, he said.
And that care will be time-consuming. "The counseling required is incredible," he explained. "You can't just take 15 minutes with a new AIDS patient."
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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