HIV 'Providers' Aren't Just Doctors: An Interview With Gerald Friedland, M.D.

Gerald Friedland, M.D. addresses attendees at Adherence 2018
Kenyon Farrow

Gerald Friedland, M.D., professor emeritus at Yale University School of Medicine, delivered the Gary S. Reiter and Andrew Kaplan Memorial Lecture at the 13th annual International Conference on HIV Treatment and Prevention Adherence Conference. His presentation, titled "Lifetime Adherence: The Role of the Provider in Maximizing the Odds of HIV Treatment Success," emphasized the importance of engaging providers, as well as expanding the definition of HIV providers beyond the clinical setting. This would include social workers, HIV test counselors, and lawyers. Friedland spoke with TheBodyPRO following the conference.

Stephen Hicks: You define lifetime adherence as the role of the provider in maximizing odds of HIV treatment success. What makes for the most ideal provider-patient relationship?

Gerald Friedland: Trust. I think mutual trust and respect are probably the most important. Honesty, a sense of compassion and competence on the part of a provider, with the primary concern being the health and well-being of the person living with HIV, and a sense of responsibility of acting on his and her behalf as the primary responsibility. For a lot of the relationship, a continuity over an extended period in which there's a sense of comprehensiveness -- not dealing with a single issue, but the overall general complexity of issues that characterizes living with HIV.

SH: When you speak of expanding our perspectives of who is a provider, who should we include this blossoming cadre?

GF: That's the array of providers who are engaged or should be available to people living with HIV. They are not all necessary for each patient but function as a team. I think that in some situations, it could be a doctor or a nurse as the primary person, but that person is also being complemented in his or her relation to the patient, that is, enhanced and strengthened by the expertise of all the other people. It may vary from individual to individual in terms of requiring all of those.

SH: At least 30% of adults living with HIV are 50 years old or older. How should providers adjust their care as people are aging?

GF: This is a new era of HIV care and treatment, and it's a gratifying, wonderful success because we have an aging population -- a population that has survived. But now, reaching an age in which other comorbidities occur in aging complicates care of HIV, so most people living with HIV have added other medical problems. It can vary, of course. Among these, it can be kidney disease, cardiovascular and metabolic conditions like diabetes, growing rates of cancer, pulmonary diseases, and certainly psychiatric diseases like depression. Also, as people get older, they tend to become more isolated and may acquire (because of these other medical conditions), more medications -- what we call "polypharmacy." People get fragile and develop deficiencies in cognitive function.

Now, this is not everybody. Certainly, not everybody at age 50, but as the decades increase and we expect people will live longer, a lot of people living with HIV will have these medical conditions. So, it becomes very important to be able to incorporate into HIV care competent, compassionate, comprehensive care for all of these other medical conditions in an organized and integrated fashion. Many HIV providers have to be competent in general internal medicine or even geriatrics, not just HIV. That requires retraining or collaborating with HIV specialists and people more familiar with the conditions of people who are aging. HIV programs are in the process of trying to organize and develop those comprehensive systems.

For many of these patients living with HIV, HIV is no longer their major health problem. They're successful and have been for decades with undetectable viral loads and robust CD4 counts, and yet they still come to their HIV provider, and many of us have become general HIV and internal medicine providers. And that's fine and wonderful.

SH: In a career that spans several decades, what keeps you going?

GF: Many of these people living with HIV, I have cared for, for decades. I know them extremely well. They know me. We have gone through this together and have this close collegial relationship as a partnership, so it's a wondrous pleasure to continue to provide.

All of these things I mention are new challenges, so HIV continues to provide challenges. Learning how to do this in this new era that we are fortunate to experience is a new challenge.

Many new issues in HIV don't necessarily involve just this aging population. There are young people at risk, so many of us are in engaged in HIV prevention types of activities, such as PrEP [pre-exposure prophylaxis]. There is still a population of young people, mostly, who are newly diagnosed with HIV. Unfortunately, there are a number of them to continue to see -- not just older people with HIV but young people, as well.

There are continuing challenges. But there's something else that I didn't bring up. We tend to think of success only in terms of viral loads and CD4 counts because that's been our biologic measures of success, but for individuals who are growing older, the quality of life is increasingly important.

The goal now, I think, for people living with HIV is to age well. This includes maintaining a healthy weight, healthy diet, exercise -- the kind of things that result in general good health.

This transcript has been lightly edited for clarity.