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Paucity of information raised HIV fear factor

A quarter century of knowledge boosts doctors' ability to treat this disease.

By Victoria Stagg Elliott, amednews staff. June 12, 2006.

In the mid-1980s, newspapers were filled with stories about a new virus, and the medical profession was wrestling with how to handle some physicians' refusals to treat those infected.

"AIDS had just arrived on the scene. It proved to be a fatal disease with no known treatment, and it was not clear how contagious it was," said Russel Patterson, MD, vice chair of the AMA's Council on Ethical and Judicial Affairs in 1987, when the panel issued a statement that physicians had an ethical obligation to care for people with AIDS.

AIDS demographics by the numbers
Timeline of an epidemic
Care evolves
Primary care checklist for HIV
Links
See related content

In hindsight, physician reluctance is blamed primarily on lack of information. The risk health care workers faced of possibly contracting the virus had a chilling effect. The stigma of homosexuality accompanying AIDS, as well as doctors' discomfort with discussions about sex that were a crucial part of related counseling, also contributed to the hesitancy.

A survey of general internists, family physicians and general practitioners published in the Nov. 27, 1991, Journal of the American Medical Association found that a majority of doctors felt they had a responsibility to treat patients who were HIV-positive or who had AIDS, though half said they would opt out if given the choice. A third were uneasy around homosexuals, and more than half responded that they preferred not to have injection drug users in their practice.

"At the beginning of the epidemic, a lot of physicians were not comfortable treating people with HIV," said Barbara Gerbert, PhD, lead author and chair of the division of behavioral sciences at the University of California, San Francisco. "Doctors were having trouble talking to patients about sex. [They] were also very worried about [their own health] and we were doing a bad job of reassuring them."

60% to 75% of primary care physicians treat patients with HIV.

Twenty-five years later, HIV and AIDS are part of mainstream medical practice. Several studies have found that, even in states where prevalence is low, between two-thirds and three-fourths of primary care physicians treat patients with HIV. A significant percentage of these doctors provide all the medical services the patient needs.

"HIV has become much more ordinary," said Ronald Epstein, MD, professor of family medicine at the University of Rochester in New York.

The reasons are multiple. First, the transmission risk to health care workers was addressed, largely through the development of infection-control protocols. Second, more can now be done for those with the disease. Additionally, the geography and demography of those testing positive has expanded.

"It's changed a lot over the years," said Dr. Patterson. "We know much more about AIDS. You really need to work at it to get it. It can be treated, and it turns out that all kinds of people can get AIDS for all sorts of reasons."

ADDITIONAL INFORMATION:

AIDS demographics by the numbers

AIDS has claimed more than a half-million American lives since 1981. About 1 million more are living with the virus -- a quarter are unaware of their status. Demographics of the disease continue to expand. Despite more optimistic prognosis, the epidemic is still expanding, especially among women and minorities. Heterosexual sex has come to account for a third of the new cases.

Timeline of an epidemic

June 5, 1981 The Morbidity and Mortality Weekly Report publishes a report of five gay men with pneumocystis pneumonia.

1982 The Centers for Disease Control and Prevention coins the term, "acquired immunodeficiency syndrome."

1985 The Food and Drug Administration approves a test to screen blood for HIV.

March 19, 1987 FDA approves zidovudine (AZT).

1990 Ryan White, a hemophiliac who contracted AIDS from tainted blood products, dies at 18. He sued his school district for the right to attend classes and was the namesake for landmark federal legislation.

1991 Magic Johnson announces he is HIV-positive and retires from basketball.

1992 AIDS becomes the No. 1 cause of death for men ages 25 to 44.

1993 The CDC expands the AIDS case definition to include conditions specific to women and common among injection drug users.

1994 The U.S. Public Health Service recommends the use of AZT by pregnant women to reduce perinatal HIV transmission.

Dec. 6, 1995 The FDA approves the first protease inhibitor, saquinavir, and highly active antiretroviral therapy -- HAART -- is born.

1996 The number of new AIDS cases declines for the first time; the proportion of the new infections among African-Americans surpasses those among whites.

1997 U.S. AIDS-related deaths decline by more than 40%.

1998 The first large-scale human trials for an HIV vaccine begin. Reports of HAART treatment failure and side effects emerge.

2003 AIDSVAX, the first AIDS vaccine to enter a phase III trial, is shown to provide no protection.

2006 About 1 million Americans are believed to be living with the virus. About a quarter are unaware of their status. More than a half-million have died since 1981.

Sources: Kaiser Foundation, Centers for Disease Control and Prevention, Food and Drug Administration, HIV Vaccine Trials Network

Care evolves

Scientific advances have transformed HIV/AIDS from an acute infection that killed its victims quickly, into a chronic disease with a more optimistic prognosis. Those infected with the virus are living longer without progressing to AIDS, and, with appropriate treatment, often are living a near-normal life expectancy.

But the story of HIV is not just one of scientific progress; it's also a story of how a virus does not necessarily stay where it started.

Someone who is infected today is increasingly likely to be female and non-Caucasian. Male-to-male sexual contact remains the most common route of transmission, but about a third of those with HIV now contract it through heterosexual sex. It's also long since escaped urban centers on either coast to cities of all sizes as well as suburban and rural areas.

What this means for physicians:

Testing for the virus is becoming more important. The Centers for Disease Control and Prevention is expected to recommend within the next month that all patients be tested at least once in their lives.
HIV patients have many of the usual preventive health care needs -- including smoking cessation, counseling about diet and exercise, cancer screening and family planning.
Treatment is increasingly similar that of other chronic conditions. HIV may be only one of several issues that need to be addressed.

Primary care checklist for HIV

HIV/AIDS has gone through a number of permutations. What began as a mysterious infectious disease became an illness with a known viral cause. At first the only recourse after diagnosis was palliative care. Now options exist to stave off advancement. And increasingly, patients with HIV find themselves receiving care from primary care physicians as well as specialists.

Overall, this evolution creates certain treatment challenges.

"It's complex, and it's going to get a lot more complicated in the next few years," said Bruce Williams, MD, MPH, professor of internal medicine/family and community medicine at the University of New Mexico Health Sciences Center.

Here is what experts say every physician needs to know about treating HIV-positive patients:

The initial evaluation could require several visits to counsel the patient on risk reduction, determine disease stage by CD4 count, assess related and unrelated health problems and answer the patient's questions.

Decisions about whether to start antiretroviral therapy will need to be made, and baseline glucose and lipid profiles taken. If therapy is initiated, it should include three or four medications prescribed in a manner that preserves as many as possible for use in case of drug resistance.

Any depression or substance-abuse problem should be treated before HIV meds are started.

Treatment effectiveness should be assessed by testing viral load. Medication effects such as nausea, diarrhea and skin rashes should be addressed to increase adherence rates.

If the drug regimen fails and the viral load increases -- either because the virus has developed resistance or the patient can't tolerate the drugs -- another combination of medications should be tried.

Resistance testing should be considered for all patients, particularly if treatment fails.

Depending on the regimen, patients should be monitored for anemia as well as lipid and glucose abnormalities. Problems with bone mineral density, redistribution of body fat and lactic acidosis are also possibilities.

The use of a multidisciplinary team of primary care and specialty physicians, social workers, pharmacists and other workers is considered the best approach. The Warmline (800-933-3413), run by the National HIV/AIDS Clinicians' Consultation Center at San Francisco General Hospital, offers one resource.