PCPs have 'significant' role in the fight against HIV, AIDS

Dec. 1 is World AIDS Day. Held annually since 1988, the CDC said the event recognizes the progress made towards prevention and treatment of HIV, and encourages progress towards an AIDS-free generation.

Elisa Choi

According to the CDC, an estimated 44,073 people in the United States were diagnosed with HIV in 2014, with the highest rates of HIV and AIDS diagnoses in the South. Although the CDC reports the number of new HIV diagnoses decreased from 2005 to 2014, it also says more than 1.2 million people in the United States have the virus, and one in eight don’t realize it.

To get a better understanding of how primary care physicians (PCPs) can help prevent the spread of HIV, Healio Family Medicine spoke with Editorial Board member Elisa Choi, MD, FACP, an internist, infectious diseases and HIV specialist in clinical practice and a clinical educator, practicing in Boston.

What is a PCP’s role in identifying patients with risk factors for HIV and AIDS?
PCPs have this important and unique opportunity to develop a relationship with the patient, to try to cultivate a comfort level that the patient hopefully will have with him or her so that these kinds of conversations can happen. That is ultimately the goal of the best primary care — developing that physician-patient relationship and it is in that context that the PCP has such a powerful, potential role in preventing HIV disease because if they can develop that comfortable rapport where the patient feels safe about talking about how they may have exposed themselves to risk or have other questions they would otherwise be embarrassed to ask, if they are comfortable with their PCP they will ask those questions, and potentially prevent HIV infection.

Currently the recommendation by the U.S. Preventative Services Task Force (USPSTF) is for clinicians to screen for HIV infection in adolescents and adults ages 15 to 65. Additionally, the USPSTF recommends all pregnant women be screened for HIV infection. Given these universal screening recommendations for HIV infection, PCPs have a significant role in identifying and diagnosing HIV disease as part of the management of preventive care for their patients. PCPs can address HIV screening as part of the routine screenings that they address with patients at physical exams, and help “normalize” HIV screening as part of the routine health maintenance and health care. They can also address the need for HIV screening at any interval visits, if there are any exposures or other risk factors that arise that make HIV infection a potential clinical concern.

What is a PCP’s role in helping patients prevent HIV and AIDS?

The PCP can play a very important role in prevention of HIV infection and AIDS. There is very good understanding in the medical community of how HIV is transmitted and what we need to do to prevent HIV infection. PCPs can help communicate that understanding about HIV transmission to their patients, and can emphasize the importance of prevention and self-care in avoiding HIV infection. This important discussion can be incorporated into a more comprehensive discussion about sexual health, which can include talking about safe sex practices. There may be a barrier to these discussions for some PCPs if they are not comfortable having these conversations with their patients, but PCPs can really play a significant role in helping to “normalize” these discussions, particularly in the context of the USPSTF universal HIV screening recommendations. PCPs also should avoid assumptions about who is, or is not at risk, for HIV infection, based on age, socioeconomic status, race/ethnicity, or any other demographic information. If a PCP does not raise these issues, then patients may not think it is important to discuss, may feel inhibited or embarrassed about raising concerns about sexual health, or may feel that such topics are “off limits.” If these conversations are handled in a sensitive way with patients, and if PCPs can reference the universal HIV screening recommendations to point out that HIV screening is part of overall comprehensive and preventive health care, it is very unlikely that many patients will be offended; they may appreciate the opportunity to better understand HIV and other sexual health issues, and feel supported about any clinical questions or concerns they have.

How can a PCP facilitate a discussion with their patient on HIV and AIDS?

The way to make this discussion as easy, successful and as comfortable as possible is to introduce it in a way that frames it as part of your general preventive health care. The fact that the current USPSTF guidelines recommend that every adolescent and adult (ages 15-65) should be screened for HIV infection really helps make that even easier. When we see patients in a primary care setting, we often address screening tests in general, and also discuss preventive care for other chronic medical conditions (ie, cancers, diabetes, hypertension, heart disease). With these USPSTF guidelines, there can be less awkwardness of asking about HIV risk factors because there is the opportunity to have a physician frame this discussion in the context of these universal screening recommendations, rather than raising HIV infection screening due to risk factors, which can make both physicians and patients feel sensitive. The general idea is to normalize the discussion of HIV screening and put it in the context of current guidelines that recommend such screening for all adolescents and adults (ages 15-65), without regard to risk for HIV. That is how the conversation can be directed in a much more comfortable fashion.

The daily oral medication known as pre-exposure prophylaxis (PrEP) is sometimes used in people at very high risk for HIV. (PrEP lowers a patient’s chances of becoming infected and the virus spreading.) When and how should a PCP discuss this option with their patients?

Often patients themselves will bring it up, particularly well-informed patients who are really savvy and up-to-date with HIV prevention measures. PCPs need to be aware there is HIV PrEP as a potential means to prevent HIV infection. Currently guidelines for HIV PrEP recommend consideration for its use in HIV-negative individuals at “substantial risk” for HIV infection, including in the following scenarios: 1) individuals who are in an ongoing relationship with an HIV-positive partner, 2) individuals who are not in a mutually monogamous relationship with a partner and who have recently tested HIV-negative, who is a) a gay or bisexual man who has had anal sex without a condom or been diagnosed with an STD in the past 6 months, or b) a heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status who may be at substantial risk of HIV infection (ie, injection drug users, bisexual male partners). PCPs may not feel comfortable managing HIV PrEP in their patients, but they should at least be aware that there is that option they can offer, in the appropriate above-mentioned clinical scenarios. Then, depending on a physician’s comfort level with HIV PrEP management, he or she can further pursue it directly with his or her patient, or consider referring patients to a specialist. PrEP is definitely part of the larger conversation of HIV risk reduction, HIV prevention and assessing a person’s particular risk for HIV.

What should a PCP be aware of in regards to side effects such as the cardiologic, fat wasting and neurologic adverse events sometimes experienced by patients with HIV and AIDS?

I think what PCPs should be cognizant of is that these medications aren’t entirely benign, but on the other hand, these side effects aren’t necessarily ones that are going to happen to every single patient, and are relatively less common. If a patient asks about long-term side effects, being aware that there are some long-term side effects that could happen and being open about discussing them is helpful. It comes down to a physician’s comfort level. Being an HIV and infectious disease physician as well as an internist, I know about a lot of these side effects because I manage patients with HIV who are on these medications. There are a lot of non-HIV, non-infectious disease physicians who may not be as familiar with the medications. I think the PCP needs to be aware that the medications used in the management of chronic HIV can have long-term side effects, but the HIV PrEP medications are overall relatively less toxic than some of the older HIV medications. If the conversation leans towards the patient wanting to start PrEP there are any number of clinical resources they can tap into, but they should also feel comfortable reaching out to HIV providers or infectious disease physicians who are comfortable managing HIV PrEP, for guidance and assistance with co-management of their patients. PCPs should know that there are certain longer term side effect concerns so they can be as balanced as possible in talking about the risk vs. benefit of HIV PrEP medications for their patients.

What is your take-home message for PCPs treating patients with HIV?

In terms of thinking about this in context of World AIDS Day, unfortunately despite a very good understanding about how HIV infection can be transmitted and prevented, new infections continue to happen. That to me, is somewhat tragic because HIV infection is very preventable. So where can we do better? We can do better by raising awareness with our patients and make sure they know how to protect themselves and what behavior changes they can make. That behavior change is most successfully implemented if a patient feels connected to their physician, if they feel that his/her physician is looking out for [the patient’s] overall health. The fact that we still have to have World AIDS Day, that we have to talk about prevention, despite more than a quarter century of understanding how the infection works, how it is acquired, how it can be prevented, speaks to a huge gap we need to overcome in better prevention strategies. I think that is one of the strengths of primary care: to be able to talk to a patient, get him or her to realize they need to invest in their health in preventing an illness or chronic disease, which is much easier to do than to manage the disease itself once it is acquired or it develops. But prevention of disease takes work, and the patient has to put in the effort. But it is much more likely to be successful if the patient feels like there is a close partnership with his/her primary care physician. In terms of HIV prevention, we can do better with PCPs overcoming their discomfort talking about HIV infection and sexual health, in general. Once PCPs become more comfortable talking about sexual health, they can more readily determine how to put their patients at ease at talking about these very important issues. Patients will sense when their PCP doesn’t want to talk about something, [which could lead to] the patient not wanting to talk about that particular topic, too. If a physician can develop an approach where he or she feels comfortable discussing HIV and sexual health, that will translate into the patient feeling more at ease and confident that he or she has a safe place in their doctor’s office to talk about the risks to which they may have been exposed. That, ultimately, can lead to prevention of HIV infection.

Disclosures: Choi reports no relevant financial disclosures.