Primary Care Takes on Greater Role in HIV/AIDS

At Southwest Boulevard Family Health Care Services of Greater Kansas City, the epidemic has continued to grow in the largely poor and minority population it serves, said Dr. Sharon Lee, a cofounder and CEO of the nonprofit clinic.

Of the 800-some patients with HIV, about a third are women, said Dr. Lee, professor of medicine in the department of family medicine at the University of Kansas. The women are acquiring the virus through sexual contact. Men having sex with men still make up the largest proportion of patients, and the majority are still white males, but minorities are disproportionately affected, she said in an interview.

Spiraling back around. While many primary care physicians found themselves treating HIV/AIDS patients at the dawn of the epidemic, that changed.

By the early 2000s, many primary care physicians didn’t feel as comfortable caring for HIV/AIDS patients because the field had become so specialized, Dr. Selwyn said.

But in the past 10 years, with HIV becoming a manageable chronic disease in this country, it is "not different in its acuity and time course from other chronic diseases that primary care doctors are used to taking care of," he said.

Dr. Lee said she became known for her specialization and often received referrals from other physicians for HIV care because the drug regimens were so complicated. But now, it makes more sense for HIV/AIDS patients to get care from a family physician or internist, she said. Primary care physicians have specific training to manage chronic diseases like diabetes, hypertension, and hypercholesterolemia, all of which are hitting HIV/AIDS patients hard.

"All of those things are things we are very well trained to care for. In fact, we are better trained than those specialists trained in infectious diseases," Dr. Lee said. The evolutionary path of HIV/AIDS care resembles "a pendulum of sorts, but more like a spiral – it’s spiraling back to primary care but it’s at a different level."

Dr. Sweet said that she’s been speaking around the country to physicians and administrators at community health centers and federally qualified health centers, urging them to funnel their HIV/AIDS patients into primary care. "It’s better to have one primary care physician than a dozen specialists," she tells them.

Building new capacity. Spreading the expertise is gaining urgency because many primary care doctors who focus on HIV/AIDS care are ready to retire. Many of these physicians belong to the HIV Medical Association or the American Academy of HIV Medicine; a majority of those members are within 10-15 years of retirement, said Dr. Selwyn, who has served on the HIVMA board of directors.

Dr. Lee, who currently serves on that board of directors, said that the organization has been seeking ways to increase training of primary care physicians in HIV/AIDS. The University of Kansas Medical Center is hoping to start an HIV medicine residency, she said.

The Albert Einstein College of Medicine has an active teaching program for family practice and internal medicine residents in HIV care and HIV primary care, Dr. Selwyn added.

Physicians and professional societies also are pushing the medical home concept as a viable model for offering lower-cost, high-quality HIV/AIDS care.

The Ryan White CARE Act, named after a teenage boy who died of AIDS in 1990, has become the main support for the AIDS-related medical home, according to Dr. Saag. The program is administered by the Health Resources and Services Administration (HRSA), a division of the Department of Health and Human Services. HRSA awards federal funds that are then used to deliver care and pay for medications. According to HRSA, the Ryan White HIV/AIDS Program is currently funded at $2.1 billion.

Funding via the Ryan White CARE Act led to the creation of multispecialty HIV clinics that deliver care through teams of providers. The clinics offer comprehensive care – from primary care to case management to counseling, social services, substance abuse treatment, palliative care, and pharmacy consultation.

The original model has evolved to helping people live, but "the overall effectiveness is just superb," said Dr. Saag, who says he believes he has data to prove the claim.

He and his colleagues studied the costs and reimbursement of caring for HIV/AIDS patients at the UAB clinic in 2006 (Clin. Infect. Dis. 2006;42:1003-10). Costs ranged from $13,885 per patient per year for those with early infection to $36,532 for those with more advanced disease. Three-quarters of the reimbursement was for medications, regardless of disease stage. Only 2% of the clinic’s actual costs for care was reimbursed. The study concluded that most HIV clinics would not survive without Ryan White CARE Act funds, as they make up a large amount of unreimbursed costs.