Health officials argue that generalists can treat HIV
Health officials argue that generalists can treat HIV
Complicated therapies raise treatment questions
With so much at stake on whether new HIV therapies eradicate the virus or fail under the pressures of resistance, AIDS experts are turning up the heat on the ongoing debate over who is best suited for treating HIV disease today specialists or generalists. The answer could have a major impact on how patients are cared for and how clinicians are trained, say federal health officials.
"The policy is that HIV is still a primary care disease and primary care providers are capable of taking care of it," says Bruce Martell, acting chief of AIDS Education and Training Centers (AETC), established by the federal Health Resources and Services Organization 10 years ago. "However, there has been an upswelling of late, by certain well-known physicians, saying that now it is getting too complex and possibly you can do harm."
Martell refers to a study published last year in the New England Journal of Medicine showing that patients treated by physicians with more experience survived longer than those treated by physicians who had limited contact with HIV-positive patients. (See AIDS Alert, May 1996, p. 56-57.) The study was based on patient data from a Washington state health maintenance organization during the past 10 years when treatment was limited to a half-dozen drugs. Since the study was published, HIV treatment has become more complex and is constantly changing.
At least get a consultation’
Despite those findings, there is concern that the guideline’s recommendations have been interpreted to mean that generalists should not care for HIV-positive patients, says Anthony Fauci, MD, director of the National Institute for Allergy and Infectious Diseases.
"The only thing the guidelines are suggesting and I think people have interpreted it a bit too much in the other direction is that when you get to the decision point about treatment when to start, how to follow, etc. that it would be a good idea to do that in concert with an HIV specialist or at least get a consultation if you don’t have considerable experience," he tells AIDS Alert. "The thing I wouldn’t want to see is that this means no one but an AIDS specialist would ever want to take care of an HIV-infected individual. I think that is pushing it a little too far."
While the new federal guidelines don’t specifically address the specialist vs. generalist controversy, they do recommend that primary care physicians seek referral or consultation with providers who have expertise in HIV care for the more difficult treatment decisions. That advice should be taken to heart, particularly for rural providers who see only a handful of AIDS patients a year, Martell says.
"If you have only two patients out of 500 that are HIV-positive, you probably don’t have enough time to keep yourself current with AIDS care," he tells AIDS Alert. "At that point, it would be wise to talk to a specialist and make sure you are not doing something wrong."
Responding to concerns that providers have less time for patients under managed care plans, HRSA has been developing an AIDS strategic care plan for managed care organizations. The plan will help guide those organizations on what services HIV-positive patients require and assure they are included in managed care programs, Martell adds.
In Chicago, the AETC serving the Midwest region recently discussed provider qualifications with its training advisory council and recognized that primary care providers have an important role in HIV treatment. "What our group has come to is that we are going to continue to want primary care providers involved in different ways depending on their expertise and involvement," says Barbara Schechtman, administrative director for the Midwest region center. "There are primary care providers whose specialty may be family practice but have chosen to take HIV as an issue. We will try to look at providers on a continuum."
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