HIV Positive

So apparently there are many patients that come to our hospital who are HIV-positive. Being on the pulmonary consult service this month I have had my share of interacting with patients who are HIV-positive and develop terrifying pneumonia. There apparently is a great deal of misinformation out there regarding the disease. Much of it has to do with the fact that people are still in denial that having unprotected intercourse can put you at great risk. Although statistically male to female transmission has a higher percentage, anybody is really at risk. Would you really put yourself at risk in general if you knew? Other signs that practitioners use to have a suspicion for a patient being HIV-positive is whether or not the patient has had a recurrent pneumonia, whether they are practicing unsafe sex (which nobody ever admits to), whether they are sharing IV needles, and some of the other signs such as unexplained weight loss.

Here are some other signs you can refer to, courtesy of the National Institutes of Health:
http://www.niaid.nih.gov/factsheets/hivinf.htm

One thing we commonly do that the hospital is put the patients and respiratory isolation because we are sometimes unsure about whether or not they may have tuberculosis superimposed. Usually the patients are released from respiratory isolation after ruling out the presence of tuberculosis (by obtaining sputum samples, chest x-ray, PPD, etc.). After confirming the diagnosis (via serology tests including ELISA), the tough aspect becomes dealing with the patient and having to tell them the prognosis for their condition.

I understand that there is always a reason to be optimistic in medicine, but how optimistic can one be without being overly optimistic? In other words, how optimistic can one be without having to put false hopes within the minds of patients? For example, the antiretroviral HAART therapy runs on the order of $20,000 per year or more. Almost all the patients we have coming through our service cannot afford it. We have instances where we will discharge patients with three medications on their list, and they will only be able to obtain one due to costs. This is just for antibiotics, not for antiretroviral therapy. I do realize that there are programs set up with the pharmaceutical companies to provide the medications via an assistance program, but I do not think long-term many of these patients will qualify for treatment for as long as they will need it. This is especially problematic because the age bracket at which people are being diagnosed varies as low as teenagers and infants (born to HIV-positive mothers).

Now getting back to the disease. If the patient does not actively take steps to take treatment to combat the replication of the virus, then there is no stopping progression to full-blown AIDS. In essence, you could say that having the disease is a death sentence since you are continually trying to play catch up to the virus. There are strains of the virus that are becoming resistant to some of medications that we have available today. This is courtesy of the World Health Organization: (http://www.who.int/drugresistance/hivaids/en/).

Rather than put false hopes into the minds of patients here, I decided to be upfront and honest with them and explain that if they are not able to take anti-retroviral medication, and they will likely progress to full-blown AIDS and could develop a catastrophic respiratory infection. I also encourage patients to discuss it with their families, currently there is a great stigma associated with having it. One of my patients became rather combative when I suggested it, but then I responded that the best thing they can do right now is educate others so that they can help prevent the spread of HIV. There is always anger with knowing that you have developed such a disease, and you cannot help but empathize. However, I do not understand why they try to project their anger at the world when in fact this disease is completely preventable. If people did not have such risky habits, then this is one less doctor-patient conversation we would need to have.

Another issue to examine is how would people who contract HIV be affected when you are within a socialized medicine program? Let's be honest, regardless of who wins the presidential election, there is a strong national movement to transform the health care system to accommodate every citizen in this country. With that, you can bet there will be some cost benefit ratio analysis. Would a nationalized medical program support financial payment for antiretroviral therapy that costs on the order of $20,000 per year or more per person when the overall mortality benefit might be marginal?

In closing, I think one of the biggest mistakes for the candidates is not discussing health care plans in detail. Is it absolutely possible to cover every person for virtually every condition without having any kind of reduction in benefits? The only organization that I know that can do everything on a fixed budget is the military, and their active duty population tends to be much healthier than the overall national population. Perhaps some questioner in the audience can address the candidates on this issue so that people will come to the realization that full coverage for everybody will not be the simple solution that they make it out to be in campaign stumps.