This is the first of a two-part series on care of the HIV/AIDS patient. Part 2 will address the public health and counseling aspects of HIV management, as well as the care of children with HIV.
It’s been a little more than a quarter-century since acquired immune deficiency syndrome (AIDS) was first identified. Since 1981, many facets of our understanding and management of HIV/AIDS have changed.
In some populations, HIV (when well-controlled) has been transformed to a chronic disease state, with few episodes of the AIDS-defining conditions (opportunistic infections, Kaposi’s sarcoma, wasting syndromes) seen in the early years of the epidemic. However, when treating underserved and indigent populations, hospitalists may still encounter the common symptoms of advanced disease in their HIV-positive patients.
What are the common presenting scenarios of HIV/AIDS seen by hospitalists in the current era of highly active antiretroviral therapy (HAART), and how does antiretroviral therapy affect hospitalists’ management of these patients? The Hospitalist recently interviewed HIV/AIDS specialists and practicing hospitalists to learn find out.
The Differential Diagnosis: Think Broadly
The Centers for Disease Control and Prevention estimates 1.04 million to 1.19 million people live with HIV/AIDS in the United States. The CDC also estimates approximately 40,000 people become infected with HIV each year.1
The conditions that bring HIV-positive patients to the hospital run the gamut. There is a broad range of presenting symptoms, noted Sigall K. Bell, MD, the Division of Infectious Diseases and General Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “The differential diagnoses for patients who are HIV-infected—depending on their immunological status—can be dramatically expanded compared to HIV-negative patients,” says Dr. Bell. “For any given presenting symptom, one needs to think about whether the person’s HIV itself, an opportunistic infection secondary to the HIV, or HIV medication effects are playing into potential explanations for the presenting symptoms.”
Even the demographics of the hospital’s catchment area can be associated with patients’ problems. “The types of problems seen in hospitalized HIV-infected patients largely depends on the degree of access to care that people have,” says HIV and infectious disease specialist Harry Hollander, MD, program director for the University of California, San Francisco Internal Medicine Residency Program, and professor of Clinical Medicine at UCSF. In areas where care systems are not robust, explains Dr. Hollander, people admitted to the hospital will most likely have the same problems seen at the beginning of the epidemic.
If hospitalists are practicing in areas with highly developed systems of care and good penetration of care, people with HIV are just as likely to be admitted to the hospital with problems completely unrelated to their HIV status. In the pre-antiretroviral era, according to Dr. Hollander, hospital physicians typically saw three or four common types of presentations in these patients. “My biggest message these days,” he says, “is to think broadly about the problems these patients present with, and to generate parallel thinking about HIV-related causes as well as causes not related to HIV. Many patients with well-controlled HIV are more likely to wind up in the hospital because of other routine medical problems. If you only consider the HIV status, you may be missing other important, related and treatable conditions.”
Thomas Baudendistel, MD, who is associate residency program director at California Pacific Medical Center, a community-based hospital in San Francisco operated by Sutter Health, confirms that as HIV patients are getting healthier, “their immune systems are being kept intact [with CD4 counts in the normal range] for longer periods of time. We don’t see issues of HIV-related conditions in hospitalization as much as we did 20, 10, or even five years ago. The life-threatening opportunistic infections, although still there, have receded as cause for hospitalization. When an HIV patient gets admitted, it’s just as likely to be a noninfectious condition, such as lymphoma, or hematologic complications. Or, the patients may be old enough to have heart disease or COPD.”