PHILADELPHIA--Personal devotion to keeping abreast of the complexity
of HIV therapy identifies the "specialist," whether trained in
infectious disease or as a generalist, John J. Bartlett, MD, said at the
American College of Physicians annual meeting.
"In the last year and a half, the velocity of new developments
in HIV disease has become so compelling, so overwhelming, that it has transformed
the field into a specialist disease," said Dr. Bartlett, chief of
infectious diseases, Johns Hopkins University. "Today, the complexity
of care right from the beginning is such that you really have to follow
the disease in order to manage HIV patients."
Know the Drugs
There are now 10 antiretroviral drugs available in the United States,
Dr. Bartlett pointed out. "To do HIV care, you've got to know about
all 10 because you're going to have to use all 10. That means you've got
to know their doses, side effects, interactions, cross-resistance, the
order in which they can be given, and their synergy and antagonism with
other drugs." But, he said, that doesn't necessarily mean that the
physician must have trained in an infectious disease specialty. "You
just have to be able to keep up with what's going on in the field and follow
an essential mass of patients. In our clinic, we define an essential mass
as one unit, which is 50 patients."
Speaking at the same session, Douglas S. Paauw, MD, echoed Dr. Bartlett's
statements. "The things I learned about HIV in my residency 10 years
ago are completely out of date now," he said. "If I had stopped
there, I would be unable to continue following HIV patients." He believes,
however, that there is an important role for the generalist in caring for
patients with HIV.
In Seattle, where Dr. Paauw is associate professor of medicine, division
of internal medicine, University of Washington School of Medicine, HIV
practice is split about fifty-fifty among physicians trained in infectious
disease and those trained in general medicine. "We also have a few
well-trained family practitioners who have taken up HIV care. So it's not
based on training in medical school or residency as much as on the desire
to keep up in the field."
The generalist also has an important role in curbing the spread of HIV
in the sense of recognizing it early, Dr. Paauw commented.
"Patients with HIV infection can present in many different ways,"
he said. "They usually come to their primary care physician. They
don't always give a risk factor history right up front, so being able to
pick up on some of the early clues of HIV is very important."
With the advent of so many new antiretroviral drugs, he added, one of
the key parts of being an HIV care provider "is being an incredible
Dr. Paauw outlined two instances in which the generalist who treats
HIV patients should probably consider referral to a specialist.
One is the case of the patient who has antiretroviral failure, that
is, has failed both a standard regimen and a salvage regimen. "I think
that's when it would make sense to refer the patient to a physician who
has treated 50 to 100 patients in a panel or is involved in ongoing studies,"
Referrals may also be necessary in patients who have persistent symptoms
despite a standard workup.