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Primary Care and Specialty Care in the Age of HAART

The complexities of highly active antiretroviral therapy (HAART) have touched off a re-examination of the qualifications and expertise needed to care for patients with HIV and AIDS. ACC's March 1997 feature, "Primary HIV Infection and the Acute Retroviral Syndrome," suggested that patients with acute HIV infection be referred to infectious disease specialists if possible. Some primary care physicians wrote thoughtful commentary taking issue with this recommendation. ACC Associate Editor Bruce Soloway, a family practitioner who has long cared for patients with HIV and AIDS, discusses the issue this month. ACC invites readers to respond by electronic mail (aidsclin@world.std.com), mail (1440 Main Street, Waltham, MA 02154), or fax (617-647-0078). -- Editors

For the past decade, primary care practitioners have done much of the work of caring for people with HIV and AIDS. Without the benefit of formal training in infectious diseases, many general internists, family physicians, family nurse practitioners, and other generalists have studied and learned about HIV and become skilled at diagnosis and treatment of HIV infection and its many complications. Particularly in underserved communities hard hit by AIDS, highly committed primary care practitioners have brought skilled and compassionate care to patients who might otherwise have been unable to access any care at all. Until recently, there has been little question that primary care providers are an essential element in our national response to the AIDS epidemic.^1-5

In the past year, we have seen, at last, the arrival of antiretroviral therapy that offers real hope for controlling and perhaps reversing the previously inexorable progression of HIV. Combinations of two or three agents chosen from a rapidly growing array of nucleoside and non-nucleoside reverse transcriptase inhibitors and protease inhibitors have shown dramatic effect at lowering viral load and improving clinical status. A new standard of care is evolving that will undoubtedly include intervention with this highly-active antiretroviral therapy (HAART) early in the course of HIV infection, when in the past we had little to offer but observation and emotional support.^6,7

The new antiretroviral therapies bring additional complexity to the management of HIV infection. Providers must now select optimal drug combinations from a much wider array of options. The currently available protease inhibitors have challenging patterns of pharmacokinetics, toxicities, and drug-drug interactions; these agents must be used with skill and caution to avoid selection of resistant viruses that may make the index patient more difficult to treat or may be transmitted to others.

In recent discussions among HIV opinion leaders, there has been growing support for the proposition that "AIDS is no longer a primary care disease." The argument has been posed that HAART is as complex and risky as cancer chemotherapy, and that it therefore can not be entrusted to primary care providers who lack special expertise in this area. This argument draws attention to the increased complexity of the new treatments, but in its rhetorical simplicity it unfairly disparages primary care providers and obscures some of the complex and subtle features of the patterns of care of people with HIV.

What Is a "Specialist"?

First, what exactly is a "specialist" in HIV? Of course, no such formal specialty exists. Committed providers from a variety of medical specialties, including oncology, pulmonary medicine, and infectious disease, as well as from primary care fields such as general internal medicine, general pediatrics, family practice, and advanced practice nursing, have developed expertise in the treatment of patients with HIV. Practitioners from all these fields have written and taught about the care of patients with HIV and have participated in the training of less-experienced providers. Repre- sentatives from all these fields have emerged as scientific and clinical leaders in the fight against AIDS. On the other hand, there are many practitioners in each of these fields, including infectious disease, who have never treated a case of AIDS. Recent studies have demonstrated that practitioners experienced in the care of HIV deliver higher-quality care and obtain better outcomes. Experience in these studies is defined as having treated between 5 and 20 patients with HIV.^8,9 No study to date has demonstrated that quality of care or outcome is dependent on the field in which the practitioner received his or her formal medical training.

We should also be precise in our use of the term "primary care practitioner." As the name implies, a primary care practitioner has the "primary" relationship with any given patient. In general, this is the provider the patient calls first with any medical problem. The primary care provider may address the problem, but if the problem falls outside his or her area of expertise, seek help from a specialist. Primary care providers must have the ability to recognize serious problems of all kinds and know the limits of their knowledge and skills. As there are enormous variations in the particular skills of primary care practitioners, there can be few generalizations about what they can and cannot do. Some are highly skilled in setting fractures, some at performing caesarean sections, and some at managing HIV infection. Whatever their particular skills, primary care providers take responsibility for managing their patients' overall care, relying primarily on their own resources but also, when necessary, on the skills of a network of specialists.

Practitioners with formal training in primary care fields develop particular skills in the management of chronic multisystem diseases, such as hypertension and diabetes. They are trained to address the primary defects in such illnesses, and they learn to prevent complications and minimize morbidity through patient education, careful routine screening, and early aggressive therapy. Primary care practitioners are also trained to attend to the emotional and social problems that result from and often complicate chronic disease.

All these skills are essential to the care of patients with HIV. A provider treating patients with HIV needs to be competent to treat HIV infection itself, knowledgeable about the prevention and management of opportunistic disease, sensitive to the predictable and unpredictable psychosocial complications of HIV, and comfortable addressing patients in crisis and facing death.

What Is a "Primary Care Provider"?

Working with this definition of primary care, it is clear that every patient with HIV needs a primary care provider. But this provider does not necessarily need formal training in primary care. Just as the HIV epidemic has propelled many primary care providers to become proficient in the treatment of opportunistic diseases, it has also led many specialists to develop their skills in the delivery of primary care. Many specialists with no formal training in a primary care field have, through study and experience, become superb primary care providers.

Can providers whose formal training was in a primary care field learn to manage the new, complex antiretroviral therapies? A similar question was raised a decade ago when primary care providers first began to care for patients with HIV. Then, of course, the therapeutic options were extremely limited. But skeptics worried that HIV was too serious and complicated, there were too many new disease entities to learn about, and that AZT was too potent and toxic for primary care providers to handle. These were plausible arguments, but they were swept aside by the energy and resourcefulness of thousands of primary care practitioners who studied and learned about HIV independently and in structured programs, painstakingly accumulating the knowledge and experience to deliver state-of-the-art care for patients with HIV in their own practices.

The new antiretroviral therapies pose a complex challenge to all practitioners, regardless of their formal training or level of expertise. Their appropriate use requires a solid understanding of viral dynamics and resistance, the use of viral load measurements, and the specific characteristics of each agent. Selection of optimal regimens will require attention to prior antiretroviral therapy, potential toxicity, and likely drug-drug interactions.

In addition, the new combination antiretroviral regimens pose a daunting challenge to patient adherence. Patients will require extensive education and persistent encouragement to take their medications at precise intervals, coordinate their medications with meals, and prevent or manage adverse effects. Failure to manage these lifestyle issues effectively may result in viral resistance to one or more agents, mak- ing future control of viral replication far more difficult. Before prescribing HAART, practitioners need to have confidence that their patients will be able to adhere to these regimens. In some cases, HAART may need to be deferred until alcohol or drug problems have been treated or complicating housing or family issues have been resolved.

Experience, Resources Are Key

Like many other aspects of HIV care, then, successful management of HAART requires both technical expertise and skill in addressing psychosocial issues. Since HAART is likely to become the standard of care for most patients infected with HIV, practitioners who care for these patients will need to be sure that they have the resources available to manage both aspects of this potentially life-extending therapy.

Practitioners who care for few patients with HIV will need to seriously consider the data showing that inexperience is associated with inferior outcomes. Such providers may need to acquire additional clinical experience with patients with HIV or consider excluding HIV from their range of practice.

Most practitioners currently caring for patients with HIV will want to continue to do so. How should these providers prepare to implement HAART in their practices? First, of course, regardless of their past formal training, they must educate themselves thoroughly about HIV viral dynamics, viral load assays, the available antiretroviral agents, and the design and implementation of combination antiretroviral regimens. Excellent educational materials on these topics are now available from a wide variety of sources. At courses and workshops across the country, practitioners from all backgrounds are receiving direct training in HAART, presenting their questions, and reviewing their difficult cases. This time-honored process needs to continue and grow.

Second, practitioners must strengthen their networks of medical consultants. Providers who are just starting to use HAART will need to identify colleagues with more experience in this area to whom they can turn for advice and support. Such arrangements will depend on each practitioner's level of confidence and skill. Many providers will feel comfortable starting initial HAART regimens with patients in the earlier stages of HIV infection, particularly those with little or no prior antiretroviral exposure. But these providers will need some more experienced backup if, for example, a patient develops a serious adverse reaction or fails to respond to the initial regimen. More complicated cases may require earlier consultation. Selection of antiretroviral regimens are likely to be far more difficult in patients at later stages of disease, particularly those who have already been exposed to multiple antiretroviral agents. In these cases, inexperienced providers may choose to consult with more experienced colleagues for initiation of HAART and may be able to resume independent care of the patient once he or she has demonstrated a satisfactory, durable response to therapy.

Third, providers will need to be sure that they have access to resources to support their patients' adherence to complex regimens. Practitioners who lack expertise in this area may need to network with nursing agencies, social workers, peer support organizations, pharmacists, and others who can provide needed supplies, services, and social support.

Fourth, practitioners should create systems to monitor the overall progress of their patient panels. Regular chart review will help to identify those patients who have not responded adequately to HAART, as well as those who have failed to return for needed follow-up and who may have fallen out of adherence to their treatments.

Practitioners who are involved in academic training programs in HIV-endemic areas have an extra responsibility to assure that their trainees have adequate didactic preparation to follow patients on HAART and that their activities are adequately monitored and supervised. Teachers will need to develop new curricula and integrate them into their programs at all levels. Regular chart review and quality assurance will be of particular importance in academic settings.

Education in the New Paradigm

In short, we need an aggressive educational campaign to bring the new paradigm of HIV care to all practitioners who currently care for patients with HIV or might wish to do so in the future. Fortunately, there is ample precedent for such a campaign. It was done successfully a decade ago, against greater odds. In the late 1980s, there were few practitioners qualified to teach about HIV and little baseline knowledge in the professional community to build upon. Today, there are thousands of practitioners with years of experience caring for people with HIV, many of whom are already well-informed and experienced in the use of viral load measurements, combination therapies, and protease inhibitors. Many of these practitioners, energized by the potential of HAART to change the face of the AIDS epidemic, are already generously sharing their expertise with less-experienced colleagues. Based on the experience of a decade ago, the resourcefulness, commitment, and potential of HIV practitioners, regardless of their formal training or current level of skill and experience, should not be underestimated.

HIV requires special expertise in the management of antiretroviral therapy, and HIV remains a quintessential primary care disease. Every patient with HIV deserves a practitioner with expertise in state-of-the-art antiretroviral therapy, and every patient with HIV needs a skilled, committed primary care provider. The most fortunate patients will find a single practitioner with expertise in both of these fields. Through education, support, and mutual respect we can create the army of such practitioners we will need to address the next phase of the AIDS epidemic.

— Bruce Soloway, MD, FAAFP

Dr. Soloway is an associate editor of AIDS Clinical Care.

Published in AIDS Clinical Care May 1, 1997

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