In some respects, the HIV clinic run by J. Michael Kilby, MD, FACP, is starting to look more like a clinic for older adults. Over 300 of the roughly 1,000 HIV patients treated at the Medical
University of South Carolina in Charleston are at least 50 years old,
said Dr. Kilby, who directs the division of infectious diseases there.
Some of the patients have been diagnosed in midlife or beyond. In other
circumstances, they've lived with the virus, sometimes at undetectable
levels, for a decade or more.
HIV specialist Donna Sweet, MD, MACP, treats a patient with HIV.
She hopes to boost the number of primary care physicians prepared to
handle all medical issues, virus-related or not, for this group of
patients. Photo courtesy of Kansas University School of Medicine
“So we are dealing with something that we weren't planning ahead for,” he said. “It's a happy dilemma to be in.”
More than 15 years after the first protease inhibitors were
approved, revolutionizing HIV medicine and abruptly commuting many death
sentences, the immune system disorder has morphed into a chronic
condition. As a result, the medical issues involved have gotten both
simpler and more complex for primary care physicians caring for patients
who happen to have HIV.
To a large extent, the virus is easier than ever to control,
particularly if it's diagnosed early and hasn't developed resistance.
The latest first-line regimens require fewer pills, sometimes only taken
once daily, and have limited side effects compared with prior
generations of drugs, Dr. Kilby said. An HIV diagnosis these days
triggers some of the same emotional and lifestyle challenges as, for
example, a diagnosis of type 1 diabetes, he said.
It might require some time to absorb the news and perhaps
incorporate the assistance of a support group. “But it doesn't mean it's
time to make funeral preparations,” he said. “It means you have to
commit to a lifetime of learning to manage your disease.”
Longer survival, though, also means that doctors are learning
firsthand how HIV interacts with the aging process, along with other
complexities, such as the cumulative impact on the body of years of
taking sometimes toxic medications, according to HIV specialists.
Primary care physicians may be assuming a larger role with these
patients, as the first generation of HIV specialists retires and
relatively few are training to fill their places, according to an
Institute of Medicine report about access to HIV care released earlier
this year.
The report's authors call for more efforts to train and support
primary care doctors, particularly in the outpatient setting where the
bulk of HIV care occurs. Also this year, the American College of
Physicians Foundation launched a three-year workforce initiative funded
by a $2.9 million grant from Bristol-Myers Squibb to improve HIV
expertise among primary care doctors.
Ironically, as HIV has become more of a chronic condition, it's not
as exciting to doctors as they choose a medical specialty, said Donna
Sweet, MD, MACP, a credentialed HIV specialist and steering committee
chair of the ACP Foundation initiative.
By pairing physician mentors with interested primary care doctors
and outpatient clinics through the workforce initiative, Dr. Sweet,
professor of medicine at the University of Kansas School of Medicine in
Wichita, hopes to boost the number of physicians prepared to handle all
medical issues, virus-related or not, for a patient with HIV. “People who do primary care medicine can do HIV medicine with some tutelage on the HIV component,” said Dr. Sweet.
Aging HIV
From 2006 through 2009, the number of Americans diagnosed with HIV
has remained relatively steady at 50,000 annually, according to the
latest data from the Centers for Disease Control and Prevention (CDC),
published in August. Gay men are more likely to be diagnosed, comprising
61% of the new HIV infections in 2009. About 27% of new cases involve
heterosexual men and women; the remainder is linked to a mix of risk
factors, including injection drug use.
At the same time, the face of HIV is aging, according to another
CDC report analyzing data from 2005. The analysis found that 15% of new
HIV or AIDS diagnoses occurred in adults ages 50 and older. That age
group also represented 24% of all those living with the immune disorder
compared with 17% in 2001.
The prognosis has never been better following an early diagnosis,
Dr. Sweet said. “There are unfortunately many clinicians who do not
understand that if you find a 20-year-old right now and treat him or her
how they should be treated, and they take care of themselves the way
they should, those people can expect to live to be 70.”
A Lancet study, published in 2008, highlighted the
improved effectiveness of medication over a 10-year span. A 20-year-old
diagnosed from 1996 to 1999 could expect to live an average of 36.1
additional years compared with 49.4 years if diagnosed from 2003 to
2005.
The analysis, based on more than 43,000 patients in North America
and Europe, also illustrated the relevance of a patient's baseline CD4
cell count prior to starting combination therapy. If a 20-year-old's
count fell below 100 cells/µL, the projected life expectancy was an
additional 32.4 years compared with 50.4 years if the CD4 count exceeded
200 cells/µL.
But not every HIV patient who walks into a doctor's office has
followed an optimal treatment path, Dr. Kilby said. “In the real world,
people don't take their medicines reliably and a lot of people suffer
the consequences,” he said. “Even if it was erratic adherence from years ago, they suffer the consequences of it now.”
Another potential challenge faces patients who may be coping with differing complications, depending on which medications they've
been taking and for how long. For example, a patient who began therapy
in the early 1990s may be coping with adverse effects, such as
neuropathy or lipodystrophy, associated with the less tolerable regimens
commonly used then, Dr. Kilby said.
Meanwhile, doctors must watch out for other diseases common in
later life, such as hypertension, diabetes and osteoporosis, among
others, some of which may be more likely with HIV. Eric Christoff, MD,
ACP Member, alerts his medical school students that HIV must be
considered an inherent risk factor for heart disease.
“What I tell them is, ‘Think of the HIV patient in terms of
coronary disease risk the same way you've been thinking of diabetics,’”
he said.
An HIV diagnosis doesn't necessarily complicate treatment for
common conditions like hypertension or diabetes, said Dr. Christoff, an
internal medicine physician and HIV/AIDS specialist at Northwestern
Memorial Hospital in Chicago. But it makes addressing those conditions
even “more pressing,” he said.
Referring out?
Dr. Sweet, a general internist who diagnosed her first AIDS patient
in 1983, continues to care for a mix of HIV and non-HIV patients, a
model that she hopes to foster in other primary care practices. Her
Wichita practice, built over 30 years, includes two nurse practitioners
and a physician assistant along with other support staff, such as case
managers.
As she describes it, HIV is one of a number of chronic diseases she
monitors in patients, more often than not through regular checkups. In
one day she may see a dozen patients with HIV/AIDS, checking on their
medication adherence, running their HIV bloodwork, keeping up with their
various Pap smears and other screening tests, giving flu shots, and so
on. “And then they make another appointment in three to four months,”
she said.
Primary care doctors or clinics, with some mentorship or training,
could easily handle these types of patients, referring out if they
encounter some complexity, such as a multi-drug-resistant virus, Dr.
Sweet said. As an analogy, she pointed out that a patient with stable
heart disease typically is monitored by a primary care doctor rather
than a cardiologist. The goal of the ACP Foundation workforce initiative is to assist
doctors not only with the latest HIV care protocols but also with
handling some of the related psychosocial concerns and taking advantage
of available funding streams.
Along with the federal Ryan White HIV/AIDS Program (the largest
provider of services for people living with HIV/AIDS in the U.S.), there
are state drug assistance programs—albeit increasingly strapped these
days—and pharmaceutical assistance programs, among others.
Dr. Sweet, who wants ACP Foundation's initiative to start training
doctors before year's end, already informally mentors a Wyoming family
physician, who has assumed the care of roughly two dozen HIV patients.
“When I go up there, she pulls out her charts and we go through her
‘problem children,’” Dr. Sweet said.
Mental adherence
Once the virus is under control, an HIV patient's needs mirror
those of others in the same age group, with some exceptions. Mental
health symptoms, for example, are more common. Dr. Christoff said that
he's become more aggressive in the last year or so about referring
patients to psychologists when mental health concerns arise. That
additional step provides some peace of mind, he said, that those needs
are being better addressed than during a time-pressed primary care
physician visit.
A 2008 study in JAIDS: Journal of Acquired Immune Deficiency Syndromes
involving 3,359 HIV patients found that 42% had been diagnosed with
depression. Michael Horberg, MD, MAS, FACP, a study author and director
of HIV/AIDS for Kaiser Permanente, described that figure as
conservative. “The likelihood is that other patients had depression, but
it wasn't identified,” he said.
Patients with HIV can develop depression unrelated to their
diagnosis, Dr. Horberg said. They also might develop symptoms in the
wake of the diagnosis or, alternatively, unidentified depression may
have led to unsafe sex and other risk-taking behaviors that made them
vulnerable to HIV in the first place.
Regardless, tackling depression also appears to help keep HIV
management on track. Dr. Horberg's 2008 study, which tracked CD4 and RNA
levels, determined that depressed patients with HIV who took a
selective serotonin reuptake inhibitor had blood results similar to
those of HIV-positive patients who weren't depressed.
Forecasting longevity
As people continue to grow old with the virus, some unique
opportunities will develop to study how HIV interacts with the aging
process and vice versa, Dr. Kilby said. After all, as the body ages, the
immune system becomes inherently more vulnerable.
It's unclear, if a patient develops kidney or heart failure or
dementia, “Were you prone to have that anyway?” he asked. “Or did you
have an additive factor because of your chronic HIV disease?” Some research shows that even patients with undetectable virus
levels carry higher inflammatory markers than the general population,
Dr. Kilby said. The body is successfully controlling the HIV infection,
he said, “but there is a cost potentially to that.”
Dr. Christoff, while acknowledging the encouraging data regarding
longevity, counted himself among those doctors who aren't convinced that
even the best controlled patient receiving optimal care for HIV and any
other conditions can anticipate the same lifespan as someone who
doesn't carry the virus.
But if primary care doctors do their jobs right, going beyond HIV
care to address high cholesterol and other risk factors, such as
smoking, then today's patient might get close, he said.
“If the patient says, ‘Am I going to live a normal lifespan?,’ The
short answer is, ‘Probably not quite that long. But if you make the
right choices and decisions, it's probably going to be almost that
long.’”
Additional reading :
The Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet. 2008;372:293-299.
Centers for Disease Control and Prevention. Estimates of New HIV Infections in the United States, 2006-2009. August 2011. Available at www.cdc.gov/nchhstp/newsroom/docs/HIV-Infections-2006-2009.pdf.
Centers for Disease Control and Prevention. HIV/AIDS among Persons Aged 50 and Older. February 2008. Available at www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm.
Horberg MA, Silverberg MJ, Hurley LB, et al. Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients. JAIDS: Journal of Acquired Immune Deficiency Syndromes. 2008;47:384-390.
Institute of Medicine. HIV Screening and Access to Care. April 2011. Available online.
Source :
http://www.acpinternist.org/archives/2011/11/HIV.html
The Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet. 2008;372:293-299.
Centers for Disease Control and Prevention. Estimates of New HIV Infections in the United States, 2006-2009. August 2011. Available at www.cdc.gov/nchhstp/newsroom/docs/HIV-Infections-2006-2009.pdf.
Centers for Disease Control and Prevention. HIV/AIDS among Persons Aged 50 and Older. February 2008. Available at www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm.
Horberg MA, Silverberg MJ, Hurley LB, et al. Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients. JAIDS: Journal of Acquired Immune Deficiency Syndromes. 2008;47:384-390.
Institute of Medicine. HIV Screening and Access to Care. April 2011. Available online.
Source :
http://www.acpinternist.org/archives/2011/11/HIV.html
Tidak ada komentar:
Posting Komentar