I gained some great insight on HIV medicine while working with my SBHCCF preceptor, a well-known HIV specialist in the Bronx community. He devotes a clinic day specifically to his HIV+ patients, many of whom he has cared for over several years. This brings up an important point - in general, HIV no longer carries with it the death sentence that it did back when it was first discovered in the 80s. It is now, if properly managed, considered a chronic disease. Therefore, family docs (my future colleagues!) are in a unique position to manage this condition, which now has a perfect home under the care of family physicians, the experts in chronic disease management.
In the tradition of the comprehensive family medicine model of care, I was able to be a part of the interdisciplinary care team meetings, which include the physician leader (the HIV specialist mentioned previously), a nurse, a social worker, a psychologist, a patient advocate/navigator, and an AmeriCorps volunteer. During the meeting, we run through the patients to be seen that day, check their latest labs (notably, the CD4 helper T-cell count and the viral load), discuss challenges and unmet needs, and develop a care plan.
I also had the opportunity to sit in on the support group for HIV/AIDS patients who receive care at SBHCCF, many of whom were in the elder demographic. It was a gift to be able to hear the stories of these patients, most of whom have carried the diagnosis for several years, and had such wise insights and an inspiring mentality of survivorship that truly moved me.
On the other side of the coin, working at the Adolescent AIDS Program (AAP) provided an interesting perspective on HIV management in youth:
"There are 56,300 new HIV infections each year in the United States, and HALF of them are in young people under the age of 25."
Clearly, there is a lot of work to be done to reach out to this vulnerable demographic in the Bronx. The AAP offers a number of services, including rapid HIV tests (eliminating the need for a return visit and possible loss to care), STI screening, ongoing medical management of HIV, extensive case management, psychiatric services, and LGBT support services, to name a few. Through this Risk Evaluation Program, a biopsychosocial model of care is employed to provide the most comprehensive support to patients to strive for positive outcomes. Adolescents are already an at-risk group simply by virtue of their developmental phase, but I became aware of other social and psychological factors that can create further challenges for them.
A significant number of youth under the care of AAP acquired the virus perinatally (while in utero or during childbirth), which is fraught with its own potential issues. Many of these children are not in the most stable family structures-- perhaps the father is out of the picture, the mother died of AIDS long ago, and the child is in foster care. One can imagine that these youth might experience very complex and difficult emotions surrounding this diagnosis that was completely outside of their control. It was sad to hear some of the stories of teens just like this who lost their battle with AIDS or are near the end. They didn't join the vast majority who have successful outcomes, because sometimes the only control they felt they had in their lives was refusing their medications. Absolutely heartbreaking.
And of course, there are many patients who come to the program after having acquired the virus sexually, oftentimes due to high-risk sexual behaviors. This carries its own host of psychosocial issues and demands focused interventions and close follow-up. I was able to be a part of an intense motivational interviewing session with such a patient, who has struggled with a number of psychiatric, socioeconomic, and relational issues that have impeded her ability to responsibly manage her HIV. This becomes a serious issue when anti-retroviral therapy (ART) is on board, because not taking one's medication consistently can lead to the development of resistant viral strains that become increasingly more difficult to treat (as in the unfortunate case of the teens mentioned above).
Investing that extra time and energy to identify barriers, connect the patient with ancillary services, and continually follow up are key approaches that are crucial in working with these adolescents. There is no one-size-fits-all. Each patient demands a tailored approach that can maximize their chances of success. And in reality, shouldn't it always be that way in medicine?
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