Primary Care Takes on Greater Role in HIV/AIDS

Thirty years after the first U.S. reports of pneumocystis pneumonia, a harbinger of the onslaught of the human immunodeficiency virus (HIV), primary care physicians find themselves again at the front lines of caring for patients with HIV/AIDS.

Like the illness itself, which has gone from a certain death sentence to a chronic disease, primary care practices evolved from first providing simple ministrations to the mostly untreatable to grappling with the specialized care needed for patients with active infectious disease, and the drug toxicities that go with their regimens. Now, HIV/AIDS care has entered a different phase over the past decade or so, in which physicians need both specialized knowledge and basic primary care skills. They must simultaneously address patients’ complications from living longer with the disease, along with their psychosocial issues and age-related comorbidities.

^{Photo credit: Cynthia Goldsmith, CDC}

The photo shows a scanning electron micrograph of HIV-1 budding from a cultured lymphocyte.

"For the first 15 years, we focused on helping people die," said Dr. Michael Saag, professor of medicine at the University of Alabama at Birmingham (UAB). "For the next 15 years, we’ve focused on helping people live – that’s a remarkable transition."

Dr. Saag said that primary care physicians who care for patients with HIV/AIDS can make an even bigger mark over the next 10-15 years. How? By showing that the care model they’ve been using perfectly demonstrates the power of the medical home.

Primary care physicians can, and should, be at the helm of HIV/AIDS care, agreed Dr. Peter Selwyn, chair of the department of family and social medicine at the Montefiore Medical Center and Albert Einstein College of Medicine, New York.

In HIV/AIDS care, "I’ve seen it start in primary care, then gravitate away, and then gravitate back," Dr. Selwyn said in an interview.

But workforce issues are a problem. Many of the primary care doctors who specialize in HIV/AIDS care now are readying for retirement. Meanwhile, some 50,000 Americans are infected each year, and the number living with the disease continues to rise. That ensures a growing patient population – unless prevention strategies, another challenge, gain more success.

And there are other hurdles, including early diagnosis and ensuring the continuation of funding under the Ryan White CARE Act, the 1990 law that has kept many HIV programs afloat.

Thirty years ago ... and today. According to the Centers for Disease Control and Prevention, the transmission of HIV in the United States has declined by 89% since the 1980s – the peak of the epidemic. With the advent of the first antiretroviral drug, AZT (zidovudine), in 1987, the number of people living with HIV/AIDS began to grow, while the number who died of it declined.

Still, today, there are 56,000 new cases a year, and some 18,000 people die annually, according to the CDC. As it was 30 years ago, men who have sex with men still make up the bulk of those infected (53%) and living with HIV/AIDS (48%). It is also the only group at risk in which new infections continue to increase.

More than a million people are living with HIV, but at least 20% don’t even know they are infected, according to the CDC.

Initially, the epidemic was concentrated in major cities on the two coasts. Now, infections are hitting Southern cities harder, and disproportionately affecting minorities. CDC data show that Miami; Jacksonville; Orlando; New Orleans; Baton Rouge, La.; Baltimore; Washington; Columbia, S.C.; Atlanta; San Juan, P.R.; and Jackson, Miss. have a high incidence of HIV. New York City and San Francisco remain epicenters.

African Americans make up only 14% of the U.S. population, but account for 46% of people living with HIV and 45% of new infections. Latinos make up 16% of the American population, but account for 18% of people living with HIV and 17% of new infections.

Patients also have a much lower socioeconomic status than they did in the past, said Dr. Donna E. Sweet, professor of internal medicine at the University of Kansas, Wichita. In her own practice, 50% of the patients are still men having sex with men, but they are less educated and less affluent, she said in an interview.

"It’s a financially and socioeconomically disenfranchised group of people compared to 20 years ago," she said.

The number of infected women in her practice also has increased. A decade or more ago, less than 10% of her patients were women. Now it’s closer to 26%; most have contracted HIV through unprotected vaginal sex, Dr. Sweet said.