This is the second in a two-part series. Part 1 appeared in the July issue, p. 29.
While the HIV/AIDS epidemic rages worldwide—an estimated 40 million people have the virus—the lifespan for many HIV-positive patients in the U.S. continues to improve.
Patients on highly active antiretroviral therapy (HAART) live long enough to develop common age-related illnesses. Those without sufficient resources and/or social supports continue to present with AIDS-defining syndromes seen at the beginning of the epidemic. Hospitalists must face these different populations of HIV/AIDS patients and their unique challenges.
In the second part of our series, we address:
- The ramifications for hospitalists of the Centers for Disease Control and Prevention’s (CDC) revised HIV testing guidelines;
- Challenges specific to managing children with HIV; and
- Ways hospitalists can make a difference with HIV patients through social services collaboration, education, and counseling.
Testing Guidelines Shift
On Sept. 22, 2006, the CDC issued revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings.1 Testing had previously been recommended only for high-risk individuals, such as injection drug users or those with multiple sex partners. The new recommendations advise testing all individuals 13 through 64 in all healthcare settings. In its rationale for extended testing, the CDC notes that of the 1 million to 1.2 million people thought to be living with HIV in the United States, nearly 25% are unaware of their infected status. Expansion of testing, the CDC argues, would mean earlier access to life-extending treatments and reduced transmission risk.
Expanded testing is a good idea, says Theresa Barton, MD, assistant professor of pediatrics at the University of Texas Southwestern Medical Center in Dallas. Dr. Barton is also a pediatric hospitalist and director of the AIDS Related Medical Services (ARM) Clinic at UT.
“According to the CDC, a large number of newly diagnosed HIV patients have no risk factor at all [other than sexual contact with a partner],” Dr. Barton says. “Many people, particularly heterosexuals, do not perceive having sex as a risk factor. That’s certainly the case for women who are pregnant. They report they have no risk factor when you know they have a risk factor by default because they’re pregnant.”
Testing should be offered to everyone in the hospital, agrees George Mathew, MD, a hospitalist with infectious disease training at Emory University Hospital in Atlanta, and instructor of medicine at Emory University Medical School. However, testing everyone who comes to the hospital may be impractical for two reasons, he believes:
- Hospitalists feel time constraints with other components of diagnosing and admitting patients; and
- Hospitalists will not be impelled to offer patients routine HIV testing unless it is mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a core measure.
“Hospitalists will need help [from their institutions] in the introduction of this recommendation, maybe as an inclusion on a general admission form or as a prompt during computerized physician order entry (CPOE),” Dr. Mathew says.
Until universal testing of all inpatients is instituted, it is still advisable for hospitalists to include HIV testing in the diagnostic workup. Neil Winawer, MD, director of the hospitalist program at Grady Memorial, one of Emory University’s affiliated hospitals in Atlanta, advises that hospitalists “should always keep the diagnosis of HIV and AIDS on their radar screen in this day and age. There can be certain things in a patient’s profile that trigger you to think about testing for HIV, such as lymphopenia, recurrent infections, subtle evidence of weight loss, or alopecia.”