Current guidelines from the Centers for Disease Control and Prevention (CDC) call for HIV testing of all patients ages 13 to 64 during routine medical visits. 1 That means the majority of the testing should be done in the primary care setting, with the primary care physician delivering the results. Yet 14 years since the CDC recommendations, studies find that only a minority of primary care clinicians provide such testing in their practices.2,3
Understanding how to manage those patients in the first days and weeks of testing could encourage clinicians to expand their testing policies.
The AIDS Reader talked to three HIV experts to get their thoughts on the top five things primary care physicians should do when a patient’s HIV test is positive.
1. Honestly assess your ability to care for the patient. “If you don’t feel you have the skills, then refer to someone else,” said Michael A. Horberg MD, clinical director for HIV/AIDS for Kaiser Permanente in Rockville, MD. The definition of “skilled” varies. He defines it as someone who has cared for at least 25 patients with HIV in the past three years; kept up to date on the literature; and attended lectures and continuing medical education programs on HIV.
Kay Kalousek DO, dean of the School of Osteopathic Medicine at the University of Arizona in Mesa, recommends that physicians refer their patients to an HIV specialist to identify a treatment regimen even if they continue to care for the patient. “There is such complexity and variety of medications compared to 10 years ago" she said.
Barry S. Zingman MD, Director of the Montefiore AIDS Center in New York City, agrees. He often sees patients whose primary care physician started them on Atripla (efavirenz/emtricitabine/ tenofovir) because it’s an easy regimen to take, but haven’t done the necessary lab work to determine if that is, indeed, the right approach, or explained the side effects in enough detail.
“The patient comes to me having already stopped the drug, or the primary care physician didn’t do the resistance test and it’s too late now,” he said. Bottom line: “Fight any urge to immediately write a prescription.”
If you do refer patients, reassure them that you will remain involved in their care, said Dr. Kalousek. “In the old days, the patient was just turned over to someone else,” she said, “and that was devastating.” So use the specialist to manage medications if you’re not comfortable with that, but provide the rest of the patient’s care yourself.
2. Order the appropriate labs. Even if you refer patients to a specialist, go ahead and order the lab work, including CD4 cell counts and viral load, as well as a genotypic assay for transmitted drug resistance. A full list is available from the HIV Medicine Association of the Infectious Diseases Society of America.
3. Begin counseling.
• First, make sure the patient understands that he or she does, in fact, have HIV, said Dr. Zingman. He sees patients whose primary care physician left them with the impression that the test was ambiguous “because the doctor is uncomfortable having this conversation or they don’t know how to deal with it,” he said. This can leave patients in doubt for weeks, intensifying an already stressful situation. It may also negatively affect the doctor-patient relationship, if the patient doesn’t think the physician is competent in this area.
• Also, highlight the fact that HIV is not a death sentence, said Dr. Kalousek. “Let them know they can expect to live a relatively normal life if they optimize their health and take their medications consistently. Tell them you know that this is not something they would have chosen, but it is manageable.”
“Talk to them about their emotional state,” said Dr. Horberg. “They’ve just been given a life-changing diagnosis. See what social supports they might need and if they need help with disclosing their status to others."
• Then have the safe sex discussion. “Often the physician is flustered with the diagnosis and lets the patient out as soon as possible, forgetting their public health role,” said Dr. Zingman. That means the patient may not receive any education about preventing transmission until they see the specialist, which risks spreading the virus.
• Assess the patient for substance abuse, said Dr. Kalousek, and refer for treatment if there are any issues. But be compassionate. “Don’t judge,” she said. “Talk about behaviors like smoking in a positive way in terms of optimizing their health.” For instance, she tells patients that smoking puts additional stress on their immune system, which is already damaged by the virus.
“This is not a 15-minute office visit,” Dr. Horberg warns, so expect to cover much of this in the follow-up visit. “You need to consider how much they want to know and how much they can take in on that first visit,” added Dr. Zingman. His patients are often “shell-shocked” he said, so he keeps the information he conveys during that first visit simple. But he also patiently answers all their questions. “They want to know if they’re going to die, if they can hug and kiss their children, if they can share food.”
He schedules his patients for a return visit in a week to go over the blood tests and provide more education, which implies another important piece of advice:
• Schedule the follow-up visit as soon as possible. “I see patients who get one visit and then their doctor scheduled them for two to three months out," he said. "That is completely unacceptable.”
4. Complete a basic history and physical. “You really do want to strip your patient down and check everything, because the destruction of the immune system can affect every organ in the body,” said Dr. Horberg. Patients should also be up to date on their immunizations, including hepatitis A and B, influenza, and pneumococcal.
5. Be prepared for these patients. That means knowing your state’s reporting requirements (available here) and how to report newly diagnosed patients, as well as having lists of local resources for HIV-positive patients such as including housing assistance, support groups, and Ryan White services. Clinicians should also already have a good relationship with an HIV specialist for referrals and consultations, Dr. Kalousek said.
Resources for Primary Care Physicians
The following sites provide additional information for primary care physicians on diagnosing and managing HIV-positive patients.
American Academy of HIV Medicine. This site contains a referral link to search for credentialed HIV providers by zip code.
Centers for Disease Control and Prevention HIV information. Includes links to treatment guidelines.
University of San Francisco’s Clinician Consultation Center. Provides a plethora of information and resources on treating HIV; particularly useful for clinicians who do not have access to a local HIV specialist.