HIV Has Become a Specialty Disease, But One Open to the Well-Informed Generalist

PHILADELPHIA--Personal devotion to keeping abreast of the complexityof HIV therapy identifies the "specialist," whether trained ininfectious disease or as a generalist, John J. Bartlett, MD, said at theAmerican College of Physicians annual meeting.

"In the last year and a half, the velocity of new developmentsin HIV disease has become so compelling, so overwhelming, that it has transformedthe field into a specialist disease," said Dr. Bartlett, chief ofinfectious diseases, Johns Hopkins University. "Today, the complexityof care right from the beginning is such that you really have to followthe 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 aboutall 10 because you're going to have to use all 10. That means you've gotto know their doses, side effects, interactions, cross-resistance, theorder in which they can be given, and their synergy and antagonism withother drugs." But, he said, that doesn't necessarily mean that thephysician must have trained in an infectious disease specialty. "Youjust have to be able to keep up with what's going on in the field and followan essential mass of patients. In our clinic, we define an essential massas one unit, which is 50 patients."

50/50 Split

Speaking at the same session, Douglas S. Paauw, MD, echoed Dr. Bartlett'sstatements. "The things I learned about HIV in my residency 10 yearsago are completely out of date now," he said. "If I had stoppedthere, I would be unable to continue following HIV patients." He believes,however, that there is an important role for the generalist in caring forpatients with HIV.

In Seattle, where Dr. Paauw is associate professor of medicine, divisionof internal medicine, University of Washington School of Medicine, HIVpractice is split about fifty-fifty among physicians trained in infectiousdisease and those trained in general medicine. "We also have a fewwell-trained family practitioners who have taken up HIV care. So it's notbased on training in medical school or residency as much as on the desireto keep up in the field."

The generalist also has an important role in curbing the spread of HIVin 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. Theydon't always give a risk factor history right up front, so being able topick up on some of the early clues of HIV is very important."

With the advent of so many new antiretroviral drugs, he added, one ofthe key parts of being an HIV care provider "is being an incrediblepharmacist."

Dr. Paauw outlined two instances in which the generalist who treatsHIV patients should probably consider referral to a specialist.

One is the case of the patient who has antiretroviral failure, thatis, has failed both a standard regimen and a salvage regimen. "I thinkthat's when it would make sense to refer the patient to a physician whohas treated 50 to 100 patients in a panel or is involved in ongoing studies,"he said.

Referrals may also be necessary in patients who have persistent symptomsdespite a standard workup.