Jarrett Sell, MD
I consider my path to caring for persons affected by human immunodeficiency virus (HIV) to be atypical, but maybe that is true of many family medicine providers involved in HIV care—only a minority of family medicine providers in the United States offer HIV care.
I, like many family medicine residents recently graduating from residency, assumed that HIV care was too complex and rapidly changing for me to become involved and that it would be unlikely to impact my future practice, particularly since I was planning to practice in a rural area. I thought that this was a condition that is best left to the care of specialists or those that planned to practice in the inner cities of San Francisco or New York. What I did not realize at the time was that HIV is everywhere and cannot be ignored by family medicine providers.
I give all the credit for my involvement in HIV care to my patients, who at times dragged me in with fear and trepidation. As a new physician starting practice in a rural underserved area, I was one of the few in our group practice taking new patients. I acquired several patients infected with HIV who needed medical—and often lots of psychosocial—care. My instinct was to tell them that I was not qualified to care for them. I was marginally aware of the complex medical regimens and myriad of side effects that they would face while on treatment and was fearful of the progression of at least one of my patients who refused antiretroviral treatment. Instead, I took a deep breath and reached out to the nearest infectious disease specialist that was an hour away and cautiously asked if they had any concerns with my starting an antidepressant on one of our mutual patients. Maybe, I began to consider, I, a family physician well versed in the management of depression, could help.
Over several years in private practice, I saw first-hand the unique disparities and health needs of persons infected with HIV and their need for understanding and competent primary care.
Many of the patients that I saw had good viral suppression on their antiviral regimens under the care of their HIV specialist that they would drive 1–2 hours to see a couple times a year. I was the one, however, that saw them most frequently when acutely ill or to help manage their other chronic medical issues. Over time I gained an understanding of how to help these patients remain in care, connect with the local HIV case management system, and talk openly about the implications of this often stigmatizing disease. With these skills, I had begun to care for a majority of the HIV-infected persons in the area. I experienced the value of coordinated comprehensive patient-centered care that is a hallmark of family medicine.
Family medicine providers cannot ignore HIV. It affects the young and old, heterosexual and homosexual, and is present in urban and rural areas. As medicine providers who are on the front lines of medical care, we are obligated to improve screening in accordance with the Centers for Disease Prevention and Control 2006 guidelines and the 2013 recommendations of the American Academy of Family Physicians and the United States Preventative Services Task Force call for us to offer opt-out screening for our patients routinely. Ignoring these recommendations will continue the trend of 50,000 new HIV infections occurring each year in the United States and leave 15%–20% of patients infected with HIV undiagnosed—as has occurred for the past several decades despite reliable testing and effective treatment.
Family medicine providers also need to bring their expertise in care coordination and chronic disease management to the care of HIV persons, who continue to struggle with poor retention in care and increased rates of cardiovascular disease, diabetes, hypertension, osteoporosis, and other diseases of the aging HIV population. As the life expectancy of those on antiviral treatment approaches those who are not HIV infected, the greatest health risks will be from those medical conditions that family medicine providers see and treat every day.
We, as teachers of family medicine, are therefore called to make sure that our future family medicine providers have a basic level of competency in the detection and care of persons infected with HIV to meet the needs of our nation and communities.
We need faculty champions willing to teach about HIV in all residency programs and experiential rotations available to residents to break down the barriers that separate HIV care from family medicine. Ignoring this educational need, or leaving it up to only a few residency programs, is unlikely to change the increased fragmentation of the health care system, marginalization of select populations, and limited preventive care that disproportionately affects those in our nation affected by HIV.
We have the tools in the United States to effectively prevent, detect, treat, and eventually cure HIV in the United States if future family medicine providers are universally trained in this significant public health issue.