Universal HIV screening opens up new set of problems for primary care doctors
From the January-February ACP Observer, copyright © 2007 by the American College of Physicians.
By Deborah Gesensway
At first glance, new CDC recommendations in favor of screening all adults for HIV infection seem relatively simple to introduce in primary care. But basic changes to routine work flow can overload a busy primary care practice. And a shortage of HIV specialists could further hamper prompt treatment.
On the positive side, HIV tests are inexpensive, quick and simple and, under the new CDC guidelines (published in the Sept. 22, 2006 issue of Morbidity and Mortality Weekly Report), physicians no longer have to get special permission from patients to order an HIV test. Known as "opt-out screening," the test should be done unless a patient specifically declines. The recommendation calls for screening everyone between the ages of 13 and 64 in the U.S. once and for screening anyone at high risk at least annually.
"They have removed the official burdensome requirements of special consent forms and for having someone trained in the office to do pre- and post-test counseling," explained Nicholaos C. Bellos, FACP, a Dallas-based HIV specialist who co-directed a course on HIV Primary Care at the Infectious Diseases Society of America's (IDSA) annual meeting last fall in Toronto.
"But," he added, "somebody has to be able to talk to the patient about the significance of a positive test or what they can do to continue to stay negative."
Here are some other concerns that physicians at the meeting had about implementing the guidelines in primary care:
New infected populations. Whereas gay men were considered in the past to be at highest risk for infection, many of the newly infected are African American and Hispanic men who do not identify themselves as gay but who have sex with both men and women.
"They perceive their risks differently," Dr. Bellos said. Misinformation exists that HIV isn't spread by unprotected oral sex, or that getting HIV differs when a man is on top or bottom during sex. "How many primary care internists are going to be comfortable having those kinds of conversations with their patients?" he asked.
According to the CDC, the most recently available data from 2004 show that 27% of cases diagnosed that year were women. African Americans accounted for half of the estimated number of HIV/AIDS cases diagnosed, whites, 30% and Hispanics, 18%. The agency noted that "At the end of 2003, an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS, with 24-27% undiagnosed and unaware of their HIV infection."
Demand for specialists. Public health advocates project that the new CDC recommendations will uncover 125,000 to 250,000 more cases of HIV and AIDS. "A lot of that care is going to need to be provided by an HIV specialist," said Daniel R. Kuritzkes, FACP, director of AIDS research and associate professor of medicine at Brigham and Women's Hospital in Boston and chair of the HIV Medicine Association. There are only several thousand HIV providers who see patients full-time in the entire country and nearly all are concentrated in a few big cities.
Complicated treatments. HIV drugs and strategies are changing quickly. Although a number of less-complicated antiretroviral strategies exist, which may make treatment seem more possible for general internists, there is a growing problem with drug resistance. In addition, many HIV patients are co-infected with other complicated viruses, such as hepatitis C, which often require specialized care.
"Once resistance is established, that resistance never goes away."
—Daniel R. Kurtzkes, FACP
"If you get something wrong initially, it can have lasting effects in terms of what regimens get used and how they get used because the virus becomes resistant so readily to treatment," Dr. Kuritzkes said. "And once resistance is established, that resistance never goes away."
Disparities. Access to care is even worse in minority communities. African-Americans and Latinos dominate AIDS cases but very few minority physicians work in HIV medicine.
Insurance issues. Practices taking care of HIV patients need to be able to help patients identify sources of insurance to cover the extremely high costs of their care. How many primary care offices know about Ryan White Act funding or state and drug company programs to assist with drug costs, asked Dr. Bellos.
Legal concerns. Taking care of patients beyond the physician's expertise can be legally risky. HIV experts are watching an ongoing malpractice lawsuit where a physician is being sued for starting an HIV patient on a particular regimen that caused significant side effects when other options were available, Dr. Bellos said.
Dr. Kuritzkes recommended general internists who identify new HIV cases through screening refer these patients to HIV medicine specialists, even though they might have to wait six months for an appointment. But there is a lot they can do to help prepare patients for treatment and to screen them for co-morbidities during that wait. A guideline on HIV primary care from IDSA is online.
"It can take a lot of time once you have the test done getting to know the patient's readiness for treatment and to determine if he is a candidate for therapy based on current virus load and CD4 count," Dr. Kuritzkes said. "Many HIV practices operate at a loss. These are complicated patients, and there is an enormous challenge of reimbursement."
In an effort to combat the steady decline of physicians interested in concentrating on treating HIV and AIDS patients, the 3,400-member HIV Medicine Association (HIVMA) has created a new clinical fellowship program for minority physicians.
With funding for several pharmaceutical companies, including GlaxoSmithKline, Pfizer, Abbot Laboratories and Gilead Sciences, HIVMA is kicking off a new one-year fellowship program for minority physicians. The program initially will fund two fellows a year for the next two years. For further information, see HIVMA's website.
For more information, see "Next weapon in the war on AIDS: Universal HIV screening," in the December issue of ACP Observer.
Deborah Gesensway is a freelance health care writer in Toronto.
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