Between 1978 and 1980, a cohort of 6,875 homosexual men were studied at the University of California, San Francisco, to determine the incidence and prevalence of a new T-lymph tropic virus, type III/lymphadenopathy-associated virus (HTLV-III/LAV), which was later called human immunodeficiency virus (HIV).1 Just a few years earlier, in 1971, the Comprehensive Health Manpower Training Act had authorized support for PA training, and in December 1972, the House of Delegates of the American Medical Association adopted “Essentials for an Educational Program for the Assistant to the Primary Care Physician,” which established standards for the education of PAs. In 1972, the Duke University PA program was one of the first to be approved to train PAs in primary care medicine.2
PAs and AIDS
In July 1981, the New York Times reported an outbreak of a rare form of cancer among gay men in New York and California; this condition was referred to at first as the “gay cancer,” but medically it is known as Kaposi's sarcoma. At about the same time, emergency rooms in New York City began to see an increase of seemingly healthy young men presenting with fevers, flulike symptoms, and pneumonia caused by the organism Pneumocystis carinii. About a year later, the CDC linked their illnesses to blood transfusions and receptive anal intercourse and coined the term AIDS to describe this new disease.
In the several years after this, more than 1,600 cases of this strange, new disease were diagnosed, with close to 700 deaths.3 As the number of deaths soared and medical experts scrambled to find a cause and, more important, a cure, PAs were in the trenches providing care and comfort to those who were infected with, and affected by, HIV.
In 1984, Institut Pasteur, in France, discovered what they called the HIV virus, but it was not until a year later that a US scientist, Dr. Robert Gallo, confirmed that HIV was the cause of AIDS. Following the identification of this new retrovirus, the first test to detect antibodies against HIV was approved in 1985, and blood banks began testing donated blood. In 1986, zidovudine (AZT), the first antiretroviral agent, was released—followed over the next several years by four classes of drug treatments and more than 25 drugs. By the end of 1987, there were 71,000 confirmed cases of AIDS in the United States, resulting in over 40,000 deaths.
Over the years, the treatment of HIV disease and its associated opportunistic infections and malignancies has become an increasingly complex and fast-changing field. In the early 1990s, AZT was found to dramatically reduce the transmission of HIV from pregnant woman to fetus—but also, in 1993, more than 75% of new AIDS diagnoses in women came via the addition of CD4 cell counts less than 200 cells/mm3 to the list of AIDS-defining criteria developed by the CDC. Invasive cervical cancer and pulmonary tuberculosis were also added to the list. In the clinic and in the hospital, PAs continued delivering care, conducting research studies with physicians, and pushing the envelope to develop a better understanding of AIDS.
The birth of PAAN
The diagnosis and management of HIV disease requires an understanding of the divergent characteristics of each patient, including risk of infection and symptoms, and a thorough consideration of the performance characteristics of a wide array of HIV diagnostic tests. From the beginning, the PA could be found in the front lines of this epidemic, ordering and interpreting tests, prescribing antiretroviral therapy (ART), and treating opportunistic infections. During this time, the PA profession began to experience a role expansion and an increase in specialization. Clinicians were needed to provide continuity of care to this new group of critically ill patients, and PAs were being positively recognized for their contributions to the workforce. The approval of reimbursement for PA services, including by Medi-Cal and Medicare, and the passage of legislation in many states allowing prescriptive privileges for PAs increased the desirability of this relatively new profession. Hiring PAs became the perfect solution to the problem of caring for people with AIDS—a cost-effective delivery system of quality health care to a largely indigent population.
Late in 1994, the first organized group of PAs practicing in HIV/AIDS care banded together to establish a national caucus of the AAPA that would become known as the Physician Assistant AIDS Network (PAAN). This organization provides colleague support, a place for interactions among PAs who work in HIV care, and educational opportunities for PAs to learn about HIV disease. PAAN offers a number of benefits, including lecture slide decks on “HIV 101,” instruction in how to take a sexual history, information about treating opportunistic infections, and advice on managing ART toxicities and side effects (http://www.paan.org/).