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Optimizing Care for Persons with HIV Infection

Frederick M. Hecht, MD; Ira B. Wilson, MD, MSc; Albert W. Wu, MD; Robert L. Cook, MD, MPH; Barbara J. Turner, MD, Society of General Internal Medicine AIDS Task Force
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From San Francisco General Hospital, University of California, San Francisco, San Francisco, California; New England Medical Center, Boston, Massachusetts; Johns Hopkins University, Baltimore, Maryland; University of Pittsburgh, Pittsburgh, Pennsylvania; and Thomas Jefferson University, Philadelphia, Pennsylvania.

Acknowledgments: The authors thank the members of the Society of General Internal Medicine AIDS Task Force who provided helpful comments on this manuscript, including Drs. Kenneth Freedberg, Allen Gifford, and Marc Gourevitch; they also thank Dr. John Stansell, who reviewed the description of the San Francisco General Hospital AIDS Clinic providers.

Requests for Reprints: Frederick M. Hecht, MD, University of California, San Francisco, AIDS Program, Box 0874, San Francisco, CA 94143-0874; e-mail, rhecht@sfaids.ucsf.edu.

Current Author Addresses: Dr. Hecht: University of California, San Francisco, AIDS Program, Box 0874, San Francisco, CA 94143-0874.

Dr. Wilson: New England Medical Center, #345, 750 Washington Street, Boston, MA 02111.

Dr. Wu: Health Services Research and Development Center, Johns Hopkins University, 624 North Broadway, Baltimore, MD 21205.

Dr. Cook: University of Pittsburgh, E820 MUH, 200 Lothrop Street, Pittsburgh, PA 15213.

Dr. Turner: Jefferson Medical College, 1025 Walnut Street, College Room 132, Philadelphia, PA 19107.

Ann Intern Med. 1999;131(2):136-143. doi:10.7326/0003-4819-131-2-199907200-00011
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Treatment advances and outcomes data have raised new concerns about how to optimize care for patients with HIV infection. This paper reviews evidence on 1) the relation between experience and type of training and patient outcomes, 2) the relation between the components of primary care and patient outcomes, and 3) primary care physicians' basic HIV knowledge and skills in screening and prevention. Several studies indicate that greater experience in HIV care leads to improved patient outcomes. The relation between outcomes and type of training (subspecialist or generalist) is less clear, and studies have not distinguished between type of training and experience. Less experienced physicians may be able to provide high-quality care if appropriate consultation from expert physicians is available. Components of primary care, including accessibility, continuity, coordination, and comprehensiveness, are associated with better patient outcomes. Optimal care of HIV infection requires a combination of disease-specific expertise and primary care skills and organization. Criteria for expertise in HIV management should focus on actual patient care experience and HIV expertise rather than on subspecialty training per se.

The management of HIV has become sufficiently complex that primary care physicians cannot be routinely expected to have extensive specialized knowledge in this area. However, many primary care physicians have weaknesses in the basic HIV-related skills that are needed in most settings, such as HIV test counseling and recognition of important HIV-related symptom complexes. Primary care physicians need to strengthen these basic HIV-related medical skills.





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