Post-publication note from Alison C. Essary, MHPE, PA-C, chair of CHAC: In this article, the Clinical and Health Affairs Commission incorrectly used the term sexual preference in lieu of the appropriate term, sexual orientation. The term sexual orientation is accepted in the scientific literature as the most appropriate verbiage, and the article has been corrected to reflect that. The intent of Clinical Watch is to provide a succinct, evidence-based overview of a clinical topic. The diagnosis and management of HIV/AIDS is complex and exceeds the scope of this manuscript. The CDC produces guidelines that may prove helpful in managing specific patient cases. Guidelines for HIV/AIDS are available at: www.cdc.gov/hiv/resources/guidelines/index.htm. Article updated on February 9, 2012.
WHO SHOULD READ THIS?
All clinically practicing PAs.
WHY IS THIS IMPORTANT?
The first cases of HIV infection were diagnosed more than 30 years ago in the United States. Since then, more than half a million Americans have died of AIDS. Currently, more than 1 million people live with HIV infection, and approximately 50,000 are newly infected each year.1 A report from the Kaiser Foundation noted that in 1995, more than 40% of Americans felt that HIV/AIDS was a national priority.2 By 2009, however, that percentage had dropped to less than 6%.2 Despite significant advances in the prevention and treatment of HIV/AIDS, the White House Office of National AIDS Policy released the National HIV/AIDS Strategy (NHAS) for the United States3 to renew focus and dedicate attention to HIV/AIDS
management. The report addresses the prevention of new HIV cases
in the United States, improving outcomes of people living with HIV/AIDS in the United States, and eliminating health disparities related to HIV/AIDS.3 Physician assistants need to be aware of the impact these strategies will have on reducing transmission rates and decreasing the prevalence of HIV/AIDS in our communities, particularly as 30 million new patients enter the health care system under the Patient Protection and Affordable Care Act.
WHAT'S NEW?
Prevention The NHAS report highlights three main themes in the prevention section and puts forth focused 5-year objectives (Table 1):
(1) Increase education on prevention in communities where HIV prevalence is highly concentrated
(2) Expand prevention of transmission through utilization of evidence-based practice tools
(3) Educate the general public on the existing threat of HIV/AIDS.
The NHAS report indicates that communities and groups with high HIV prevalence and incidence (Table 2) should engage in intensified education and prevention actions. Groups at high risk, such as men who have sex with men and injection drug users, should receive resources, tools, and amenities on education and prevention.3 Finally, program accountability must be in place to understand the methods and utilization of resources.3
The report emphasizes that prevention must be conducted using evidence-based approaches, suggesting that single-focus education practices, such as abstinence-only programs or condom usage campaigns, are not effective.4 According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), duplicative, overlapping, and combined prevention education is more effective in preventing new infections than are isolated singular messages.5 Evidence suggests that HIV-positive people tend to take steps to avoid disease transmission.6 Thus, the NHAS report recommends improved funding for the utilization of innovative combined awareness and prevention strategies that target high-risk geographic and community groups. Finally, in order for prevention education to be effective, broader audiences must be reached, and the NHAS report indicates that all groups and communities should be inundated with social marketing campaigns and promotion of age-appropriate education on HIV and sexually transmitted infections (STIs). Sustained outreach programs and seminars should be included in order to maximize educational effectiveness.
Improving outcomes Three main goals were identified in the NHAS report in order to appropriately address the second principle of improving patient outcomes:
(1) Establish a seamless system to facilitate continuous and coordinated quality care
(2) Increase the number and diversity of available providers
(3) Provide support for people living with HIV who have comorbid conditions.
One potential solution may be implementing programs that immediately link patients with new diagnoses to quality care through a network of communications and availability of funding and resources. Early initiation of antiretroviral therapy has been demonstrated to improve outcomes.7 In addition, promoting collaborative opportunities among health care providers and health care services, with the use of electronic medical records and information technology media, will aid in establishing a seamless coordination of care.
Identifying, training, and increasing clinically competent health care providers is another recommendation of the national strategy to improve outcomes in HIV/AIDS patients. This can be done by incentivizing primary care providers and reproductive, sexual, and mental health care experts to provide HIV/AIDS services. Finally, the report indicates that overall outcomes will be influenced by the provision of housing, food, transportation, and other supportive services to persons with HIV/AIDS by federal and state agencies. These services will aid in the adherence to and maintenance of treatment regimens and management of comorbidities.