Drug interactions become a factor when, as is common, children develop seizures, says Dr. Barton. “It’s sometimes difficult to find drugs that don’t have a lot of interactions, so obtaining the advice of the pharmacist is really crucial,” she says.
Adolescents are a particularly troublesome subset of growing HIV cases. “By nature of their being adolescents, they do not routinely access care,” notes Dr. Barton. “There is a long window of time—often many years—before a patient becomes symptomatic, so they may not present until they are severely ill.”
Inpatient Management
If and how hospitalists interact with HIV/AIDS patients depends on their institution’s resources, catchment area, and formal affiliations with teaching hospitals. Tomas Villanueva, DO, is a hospitalist at Baptist Hospital of Miami, a 650-bed not-for-profit hospital in South Florida.
“I’m one of those very spoiled hospitalists because I have everything and everybody available to me,” he says. “I have the good fortune to work with infectious disease doctors and with clinical pharmacologists.” Access to these consultants, he says, helps with admitting HIV patients taking antiretrovirals, especially when withdrawing oral nutrition is indicated.
“Atlanta has a large HIV-positive population,” notes Dr. Mathew. As in many U.S. urban centers, patients in Atlanta often present with opportunistic infections and end-stage AIDS. Dr. Mathew advises hospitalists to consult with the infectious disease specialist when HIV/AIDS patients are admitted. “You call the nephrologist when you have an end-stage renal disease patient, so you should call the ID [infectious disease] specialist when you have an HIV patient,” he says. “There are multiple presentations of antiretroviral toxicities, which most hospitalists do not know how to handle. Yet it is also not advisable to take them off their HAART presumptuously.” Dr. Mathew also observes that many HIV patients consider ID specialists their primary care providers, so it is important to respect that bond while patients are in the hospital.
Accessing the expertise of ID specialists who work on the teaching service can help hospitalists stay abreast of treatment trends, notes Dr. Winawer. Because of Grady Memorial’s affiliation with Emory University, house staff can access the expertise of the university’s world-renowned ID program through the teaching service. As a result, house staff are more aware of issues related to treating HIV/AIDS, he says.
Hospitalists likely will not be the lead physicians for managing HIV/AIDS patients once admitted, especially if their institutions are affiliated with university teaching hospitals. However, hospitalists can still have an impact on providing essential public health messages and improving the quality of care. HIV and ID specialist Harry Hollander, MD, program director for the University of California at San Francisco Internal Medicine Residency Program and professor of Clinical Medicine at UCSF, notes that hospitalists can play a reinforcing role by educating patients to modify risk behaviors. For instance, he says, “If patients are admitted with complications of risk behaviors that may be associated with HIV infection—such as sexually transmitted infections, or medical problems related to injection drug use—addressing those issues becomes as important as imparting a smoking cessation message to someone who comes in with pneumonia or pulmonary problems.”
Emphasizing links to care is another key role for hospitalists. At Grady, reports Dr. Winawer, at least 60 inpatients with HIV/AIDS are being treated at any given time by the four immunology service teams run by the Department of Infectious Diseases, as well as 12 ward teams and four ICU teams.
Most indigent patients do not have strong social support, so Dr. Winawer emphasizes how hospitalists can provide compassionate care by collaborating with social workers. For example, HIV patients admitted to the hospital with respiratory illnesses might be placed in isolation to rule out tuberculosis. “Many times these patients do not have good family or other social support, and they are left in their room to dwell on their diagnosis. It can feel very isolating and demoralizing if they do not have knowledge of services that can be offered to them. So it is critical to involve social services at that time.”