Ronald H. Goldschmidt, MD, discusses when and how primary care physicians should care for patients with HIV.
For clinicians who are not experienced in providing care to patients with human immunodeficiency virus (HIV), it can be daunting to consider managing long-term care for a chronic HIV patient. But with the right tools, and the willingness to seek consultation when necessary, it can be done said Ronald H. Goldschmidt, MD, a professor at the University of California at San Francisco and director of the national Clinician Consultation Center.
Ronald H. Goldschmidt, MD
Goldschmidt believes the goal is not to address whether PCPs without HIV care experience should care for HIV patients, but to create a system that allows all physicians to provide the best possible care their patients with HIV.
The time is ripe to tackle this subject, Goldschmidt told Medical Economics, because antiretroviral therapies have transformed the trajectory of HIV disease, increasing the probability that physicians in all care areas will encounter patients in early or manageable stages of the disease.
Goldschmidt spoke with Medical Economics about what this means for primary care providers.
Medical Economics: What are the most complicated aspects of managing HIV from a medical perspective?
Goldschmidt: [There] are two things. One is opportunistic infection, for which infectious disease experts are often needed, but those occur very infrequently now because of the effectiveness of antiretroviral treatment and prophylaxis against opportunistic infections.
The second most common difficult thing we are dealing with is antiretroviral resistance when the combination of antiretroviral medications isn’t working. For the most part, that occurs in two circumstances. The first is that someone’s been on a regimen for a very long time and it’s not a very powerful regimen and it loses its ability to keep the virus in check. The second most common cause of that is intermittent therapy, when someone sometimes just doesn’t take their medicines every day. And when that happens, drug resistance can occur fairly quickly; sometimes within days or weeks. And that will make the entire drug regimen not as effective. Sometimes that occurs because people get sick from other things and they don’t take their medicines or they can’t take their medicines. Other times, there are problems with access to their medications, and that can occur even with good insurance. It shouldn’t happen but it does because there are so many moving pieces of the medical system these days.
Medical Economics: What are some complications of antiretroviral and other HIV therapies that PCPs might see in practice?
Goldschmidt: During therapy and later in life, patients can face diabetes, high lipids, some renal issues like HIV nephropathy, and there are a number of cardiac problems that occur more frequently. So what we have to do then is combine both excellent HIV care and excellent general care in this new world we’re living in with patients living so much longer.
Medical Economics: Is it the role of the PCP to manage HIV-specific treatment, or just routine medical issues? When should a PCP reach out to a specialist for help with HIV-specific issues?
Goldschmidt: The role of the primary care clinician is to manage both. Sometimes you might need consultation when starting antiretroviral drugs in a newly diagnosed patient, but after that it generally is a matter of managing and watching for side effects-the same as it would be if you were giving specific drugs for any other condition. So for all of the many drugs and diseases the primary care clinicians deal with, we have to develop our own sense of when we need consultation on each of those. We know we need to watch for complications of all of our therapies and in a way it’s the same in HIV. We need to monitor for toxicities, and if they get into trouble we need to consult with an HIV specialist. But the majority of care for persons with HIV can be done by the PCP.
Medical Economics: How can PCPs best prepare themselves to care for HIV patients in cooperation with the patient's specialist? How is telemedicine helping PCPs work together with a patient's HIV team and in coordinating care for patients?
Goldschmidt: There are so many different ways of coordinating this care but most PCPs will have their selected specialists they consult with. If they are consulting with an HIV specialist, those tend to be people who are internal or general medicine who have spent extra time managing HIV patients. There are some telemedicine programs with HIV consultation, but there are also telemedicine programs, like Project Echo, that actually provide small group training and consultation by telemedicine. That would be for the clinician who really wants to expand their knowledge and their care of HIV.
Medical Economics: What do you see as the biggest hurdles for PCPs in managing HIV patients and how can these hurdles be overcome?
Goldschmidt: The first thing they have to understand is that the old dogma that these are very sick patients who need so much time and intensive care is really not true so much anymore. After they’ve gotten started on the antiretroviral drugs they are very much like diabetic patients that need periodic monitoring. The management of the HIV does not necessarily take up all that amount of time and include what it did in the past. Consultation might not be necessary for years after starting a patient on treatment.