November 21, 2011
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
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?
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.