Researchers weigh continuing benefits of having HIV specialists
Coordinated system of care best option
HIV care in industrialized nations might best be served by a coordinated system of care that includes a general practitioner working with an HIV clinic, research suggests.
A recent study shows that initial HIV treatment once was complex and varied, but now is largely homogenous.1
This is good news from a clinical perspective because it suggests that HIV clinicians and specialists could devote more of their time to the complex cases of patients who have received treatment and now are experiencing treatment failures. Or they could focus on patients with complex comorbidities.
The simpler regimens needed by most new patients could be handled by general practitioners, who are working with HIV clinics, a researcher suggests.
There are two major clinical trends in HIV treatment, and the first is the increase in patients needing help from HIV clinics, says James Alexander McKinnell, MD, a fellow in infectious diseases at the University of Alabama at Birmingham, AL.
"If you look at currently-funded Ryan White clinics, they're running at capacity, and there's not much room for these clinics to grow and expand," McKinnell says. "They're experiencing a crisis in maintaining an HIV workforce."
The second trend is that HIV clinicians are doing very well with HIV care and treatment, helping patients live longer than once imagined possible.
Antiretroviral therapy (ART) might have reached its state-of-the-art moment.
For many HIV patients, HIV disease is not necessarily their primary concern. Their issues might be blood pressure and cardiovascular disease, McKinnell says.
"Up until 2002, ART regimens were very complicated," McKinnell says. "By comparison, now the guidelines are more simplified, and there's becoming a standard of care."
Although no one has formally said there is a standard of care model, McKinnell and co-investigators have found that this is what HIV clinical practice suggests.
"The purpose of our study was to look at how regimen selection has changed over time," McKinnell says. "What regimens do we use for initial therapy in each calendar year?"
Researchers found that this has changed dramatically in the past decade.
From 2000 to 2006, the number of unique initial regimens ranged from 10 to 16. Then there was a precipitous drop in 2007, and since then the number of unique initial regimens has been two to four. The number of regimens used in initial therapy ranged from 15 to 25 and then dropped to six in 2007.
"In 2003-2004, there were a whole bunch of regimens used, and HIV care was very complicated," McKinnell says. "In 2007, more than 90% of patients were started on one of two regimens."
So over the past few years, providers and patients have developed a preference for what they think is a good initial therapy, McKinnell says.
"I looked at the number of initial regimens used to treat 100 naïve patients, allowing for comparison from year to year," McKinnell says. "If I look from 2000 to roughly 2005, that number ranges from 15 to 25 regimens per 100 patients."
Then in 2007, the number dropped down to six, suggesting that variability has decreased, McKinnell says.
"People are becoming more homogeneous in what they're using in regimens," he adds.
"For decades we've been approaching HIV patients with the mindset of 'We're going to try to take care of the patient, and we'll try to do everything for the patient,'" McKinnell says.
"At most HIV clinics, we're really adept at handling psychiatric issues, social issues, and a coordinated comprehensive model of care, and that's how we handle it," he explains. "When you look at other diseases like diabetes you find that the quality of care model [most often employed] is inferior to the HIV one where someone is coordinating everything."
So it's worked well to have a health care team that includes social workers, psychologists, case managers, and others work with HIV patients, who primarily are treated by HIV or infectious diseases specialists.
But for people receiving initial HIV treatment, the specialist's role might be augmented by a general practitioner who could assess the patient's whole health picture at each visit.
The HIV prescribing patterns research would suggest that the HIV treatment model would benefit from the inclusion of general practitioners, McKinnell says.
A general practitioner who works with an HIV or infectious diseases specialist would provide more holistic care.
"We utilize general medical specialists in our system [at the University of Alabama at Birmingham HIV clinic]," McKinnell says. "The primary care is a group process; if I recognize that my patient has diabetes, then a diabetic consultant will come in and get involved."
McKinnell is the one responsible for making sure all of the necessary medical care is provided.
Under Ryan White Care Act funding, the HIV physician needs to be at the center of the care model, he notes.
"This is great because Ryan White allows for all of the needs of the HIV patient, including social work, pharmacy, mental health, and drug abuse counseling," McKinnell says.
"Ryan White allows my clinic to provide coordinated care to these patients, and without that funding, we couldn't afford to do that," he adds. "It encourages a coordinated care system."
Transferring new HIV patients to community physicians probably would be a big mistake, McKinnell says.
"It's easy to say we should have general practitioners choose the initial regimen and go from there," he explains. "But although it's an easy solution, it's not very viable."
If HIV clinics send the overflow of patients to primary care clinics, then the primary care clinics won't have the funding to make decisions on subsequent ART regimens, McKinnell says.
"But we would love their help in managing patients," he says. "If you have a primary care provider and an infectious diseases provider working together on a patient, then you get the best of both worlds: good virological control, good cardiovascular care, and general internal medical care."
This coordinated system of care is the ideal model, McKinnell says.
Reference
- McKinnell JA, Willig JH, Westfall AO, et al. Contemporary antiretroviral therapy: Is it time for the generalist to return? Poster presented at the 48th Annual ICAAC/IDSA 46th Annual Meeting, held Oct. 25-28, 2008, in Washington, DC. Poster:H-1260.
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