TRUTHS AND CONSEQUENCES
So perceptions and assumptions play important roles in how the US addresses HIV testing—both the perceptions of some patients that they are not at risk or that having HIV isn’t a big deal anymore, and the assumptions by health care providers that they don’t need to screen all patients for HIV. That faulty logic can have dire consequences, even if HIV is no longer an automatic death sentence.
“I think there’s a lot of passive testing, a lot of disease-induced or behavior-induced testing,” Ogunfiditimi says. “A patient comes in with complaints of what sounds like a sexually transmitted infection and that may spur a provider to initiate the discussion around HIV and subsequently do testing to back that up. But I don’t get the sense that HIV testing is promoted significantly.”
“They get sick” is how Stewart says many people learn their HIV status. “That is still frequently the way people become aware of their illness—they are sick in the hospital with an opportunistic infection…. If we can identify people who are HIV-infected earlier, we can capture them at higher CD4 counts, and then they have an improved life expectancy. We can start treatment, and that also impacts transmission.”
Echoing Stewart’s comments, LeLacheur also notes that the major pneumonia or other infection that leads to hospitalization and diagnosis of HIV can cause permanent damage. “I have a couple of patients who appear to be poststroke because of a viral infection in their brains that people get very late in HIV,” she says. “Now, their viral loads are undetectable and their CD4s are very high. Their immune systems are in good shape, and in every other way they’re healthy. But they can’t walk.”
For those misguided patients who think HIV isn’t such a big deal these days, LeLacheur has some hard facts clinicians can share. “You don’t realize until after you have HIV and someone explains it to you that the minute you get it, it essentially knocks out the entire immune system in your intestinal tract—which is more than half of your immune system—and that’s never coming back,” she says. “That infection in the gut is never going away; the medicines don’t touch it. So your digestion will never be right. There are things we can’t fix about HIV.”
And heaven help the patient who tries to rationalize that “you just take one pill a day.” First of all, that one pill ties up your liver, as LeLacheur points out, and second of all, HIV medications cost about $16,000 a year. Not many people can afford that on their own, and some states have 700-person-long waiting lists for assistance programs.
The consensus among clinicians who treat HIV-infected patients is that, yes, the US is much better off than it was at the height of the crisis. But there is still enough disease, still enough devastation, to warrant continued vigilance. And that starts with talking to all patients about HIV.
Ask the questions, they advise, do the test, and be prepared to refer patients to a specialist who can help them manage their illness. But don’t drop the ball on those patients even when they have specialty care; study up on drug interactions and know what you are prescribing to patients taking antiretroviral therapy.
“As PAs and NPs, we absolutely have to be the ones carrying that banner up front,” Ogunfiditimi says. “We’re the ones who have that opportunity to spend time with those patients and make sure we walk them through the urgency and the importance of being aware that this disease is still very rampant in our communities. I don’t want to say that we have taken it for granted, but we have definitely not paid as much attention as we used to in the ’80s and the ’90s, and we need to get back to that.”
“We can never forget,” Stewart concludes. “We spend a lot of time learning about and testing for breast cancer, prostate cancer, diabetes, and hypertension, all in an effort to take care of our patients the best we can. Screening for HIV should be in that same category.”
Reprinted from Clinician Reviews. 2012;22(6):cover, 11-14, 33-35.