{"id":10668,"date":"2023-04-28T10:52:51","date_gmt":"2023-04-28T14:52:51","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=10668"},"modified":"2023-05-02T18:16:10","modified_gmt":"2023-05-02T22:16:10","slug":"what-is-the-future-of-hiv-primary-care","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/what-is-the-future-of-hiv-primary-care\/2023\/04\/28\/","title":{"rendered":"What is the Future of HIV Primary Care?"},"content":{"rendered":"

Here’s a figure I’ve made for an upcoming talk, which is entitled “The Future of HIV Care.” It summarizes several eras in HIV treatment, finishing up with the current unprecedented successful phase where most people with HIV take 1\u20132 pills a day, have virologic suppression and no clinically apparent immunodeficiency. HIV is often the least<\/em> of their medical problems.<\/p>\n

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To put this into context, a patient at our hospital recently found out that the cause of their several months of fatigue and weight loss was HIV, and expressed relief that it wasn’t diabetes or cancer. And on hearing this comment, all the people on our HIV treatment team agreed that the management would indeed be easier, and more likely successful.<\/p>\n

I don’t mean to diminish the potential severity of HIV, which of course can, undiagnosed and untreated, still be lethal. Far too many people in this country with HIV are either undiagnosed, or diagnosed and not engaged in regular care or treatment<\/a>. Getting them on therapy remains an urgent individual and public health priority.<\/p>\n

But for those in care<\/em>, as an example of medical progress, HIV treatment stands out as a phenomenal success.<\/p>\n

This success begs the question, once again, of the role ID specialists should play in the management of people who have HIV once they are on stable ART. When I last covered this topic here on this site nearly a decade ago<\/a>, we were in the tail end of Era #4 above — and since then treatment has only gotten better.<\/p>\n

For emphasis, I still believe ID doctors and HIV specialists should play a primary role in handling new HIV diagnoses, managing opportunistic infections and other complications, interpreting resistance testing, and helping guide treatment switches, especially as new options arise. The nuances of figuring out the best candidates for long-acting cabotegravir-rilpivirine certainly have put a recent premium on our expertise.<\/p>\n

But the stable septuagenarian on one-pill ART whose major problems are hypertension, osteoarthritis, and, yes, type 2 diabetes? Who among us can claim that we’ve kept up sufficiently with these non-ID issues to be their ideal primary provider? If you, as an ID specialist, were given the option of attending an educational session from a brilliant speaker on “Advances in the Management of Invasive Fungal Infections” or “Advances in the Management of Type 2 Diabetes,” which would you choose?<\/p>\n

We should not give up HIV care, but potentially shift it to be handled more like other medical specialties. Oncologists and rheumatologists, to cite two examples, play the dominant role in their respective diseases when treatments are active and monitoring is intense. But neither specialty takes on full primary care once the patients are rock-solid stable.<\/p>\n

Pushing against any such distribution of HIV care to generalists is that most (importantly, not all) of the primary care workforce hasn’t been doing very much in HIV management. It’s notably concentrated in a very small fraction of U.S. clinicians. As an example, a patient of mine recently was told by their PCP that they wouldn’t order their routine monitoring tests — CBC, comprehensive metabolic panel, and HIV RNA — because “only ID can do that.” This is of course an extreme example (and certainly not true), but the anecdote shows how far from HIV general practice is for most people doing primary care.<\/p>\n

Another important perspective comes from our patients, some of whom we’ve followed for decades. They may not be comfortable switching primary care, especially with a disease that still sadly confers some societal stigma.<\/p>\n

So let’s re-do the poll and see what you think. As usual, I very much welcome in the comments section your opinions about this issue — and will select a few choice views for the talk!<\/p>\n

Thank you.<\/p>\n

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Should ID doctors still do primary care for stable people with HIV?<\/strong><\/p>