World AIDS Day: Addressing comorbidities, resurgence and stigmas

As HIV/AIDS management moves from acute to chronic care, World AIDS Day is a time to celebrate progress and map out a plan for the future. For primary care physicians, it’s also time to reflect on where they fit in when it comes to managing patients and fighting a resurgence.

"The whole point of World AIDS Day is to think back on the patients that were lost, especially when the epidemic was raging and we didn’t really have any real treatment. That was a horrible time," John S. Cullen, MD, FAAFP, president-elect of the American Academy of Family Physicians (AAFP) and a family practitioner from Alaska, told Medical Economics. "Now, the treatment has gotten so much better that we’re seeing people have medical problems consistent with age.”

John S. Cullen, MD, FAAFP

HIV/AIDS is much more of a chronic condition than a fatal disease today, thanks to effective treatment strategies including antiretroviral medications. Although some conditions patients with HIV/AIDS face may be due to the medications they take to manage the disease, Cullen said in a way it's a miracle that many of these patients are living long enough to have to battle diseases like heart disease, high cholesterol and cognitive issues. In the past, HIV/AIDS patients would not have lived long enough to develop most of these conditions.

World AIDS Day is time for patients and providers to reflect on how far the management of HIV/AIDS has progressed, Cullen said. Observed on December 1 each year, the theme for this year’s World AIDS Day is "Increasing Impact Through Transparency, Accountability and Partnerships." According to the a statement by Deborah L. Birx, U.S. Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy at the Department of State, the theme is meant to be a reflection of the nation's leadership in fighting the AIDS epidemic both at home and abroad.

Next: The importance of primary care

The road begins at primary care

The fight at home begins many times in primary care offices, Cullen said. PCPs are often the first to diagnose HIV/AIDS, and can initiate therapy in coordination with an infectious disease specialist. In many cases, he said, a family physician will continue to treat HIV/AIDS patients by maintaining a plan of care and managing comorbidities.

The benefit to caring for these patients in the primary care setting is the extended focus on issues beyond HIV/AIDS, he said.

“We really do focus on the psychosocial issues as well, especially in the patient-centered medical home,” Cullen said. Resistance has developed to antiretroviral therapies because some patients are not consistent with their medication regiments, he said. Primary care offices are well suited to helping these patients address barriers to care and medication compliance, and dealing with a host of other issues that could impact their care.

A report on the role of primary care physicians in HIV/AIDS management highlights the success of antiretroviral therapies in managing HIV/AIDS while warning that non-AIDS comorbidities have emerged as primary health issues. There has been some question whether the care of these patients and their chronic conditions is best managed by a specialist or by a PCP. The study found that 59% of patients use their HIV physician as their PCP, and 84% said they would prefer that model. Researchers also found that about 60% of physicians want to provide both primary and HIV care. The study, conducted through surveys of 98 physicians and eight HIV specialists at a Los Angeles HIV clinic, found that the physicians polled were more comfortable with antiretroviral therapy and opportunistic infections than in managing non-AIDS comorbidities. The majority of those polled-81% of patients and seven of the eight physicians-said they would be in favor of having a primary care physician housed at the HIV clinic.

The study concluded that while patients would like to integrate their HIV and primary care, HIV specialists may not be comfortable enough with managing non-AIDS chronic conditions and comorbidities.

The need is still great

Studies like this and the observation of World AIDS Day are reminders that there's still much work to do to achieve optimal treatment of HIV/AIDS patients, Cullen said.

"We still are not optimally treating as many people as we could be. Roughly 70% of HIV patients are not being suppressed," Cullen said.

He also worries about a resurgence of fatal HIV/AIDS, particularly when it comes to resistance to existing therapies and to an uptick in high-risk behaviors brought on by the opioid crisis.

"The opioid crises makes me very nervous," said Cullen, remembering how the early days of the AIDS epidemic was linked to use of intravenous drugs like heroin. "As we scale back opioid use, we are seeing an increase in heroin use. Heroin was big driver of [the HIV/AIDS] epidemic early on."

The key is surveillance, support for treatments, continued research, and continued work to address the stigma that these patients face.

“One of the issues historically, and I think that’s why World AIDS Day is a celebration, is that there’s a stigma associated with HIV that there really should not be. This is a disease like any other disease. It’s complicated, but it’s not any more complicated that a lot of the other things we take care of,” Cullen said. “The important thing is to get beyond the stigma. We do need to do a better job of identifying it and treating it.”