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A
Guide To Primary Care For
People With HIV/AIDS, 2004 edition |
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Chapter
1
Primary Care as Chronic Care
John G. Bartlett,
MD
Laura W. Cheever, MD, ScM
Michael P. Johnson, MD, MPH
Douglas S. Paauw, MD, FACP
What
is a primary care approach to the treatment of HIV/AIDS and why
is it important?
TOP
People with
HIV/AIDS can live longer, healthier lives because of advances in
treatment of HIV infection. However, longer lives are associated
with increased prevalence of 1) adverse effects of HIV infection,
2) adverse effects of the drugs used to treat HIV, and 3) concurrent
medical conditions that would occur in the absence of HIV. These
long-term complications have put HIV infection in the realm of chronic
diseases rather than of infectious diseases, which usually respond
to short-term clinical interventions.
Effective management
of chronic diseases in the primary care setting requires the coordination
of interventions that occur at the level of the clinical services,
the community supports for those clinical services, and the individual
patient. While clinical services begin in the primary care clinic,
community supports are needed, and the patient must be engaged to
enhance self-management. The coordinated interventions together
contribute to the desired clinical outcomes. The Chronic Care Model,
which is used in the design and quality improvement activities of
clinical services, conceptualizes how these factors impact the clinical
outcome of chronic disease management (see Figure 1-1).
Figure
1-1. The Chronic Care Model
Examples
of Chronic Care Model Interventions
Self-Management
Support: Emphasizing patient role, assessment, problem-solving,
and interventions to enhance self-management
Delivery
System Design: Defining care team, planning visits, follow-up
reminders, continuity of care, and referral system
Decision
Support: Use of clinical guidelines, provider education,
and specialty support
Clinical
Information Systems: Establishment and maintenance of
patient registry, use of registry for patient follow-up, and
quality improvement
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Source: Adapted
from Wagner EH. "Chronic disease management: What will it take
to improve care for chronic illness?" Effective Clinical
Practice. 1998;1:2-4. Reprinted with permission. The Chronic
Care Model was developed by Ed Wagner, MD, MPH, Director of the
MacColl Institute for Healthcare Innovation, Group Health Cooperative
of Puget Sound, and colleagues with support from The Robert Wood
Johnson Foundation. Further details can be found at www.ihi.org.
What
is the purpose of this guide?
TOP
This book addresses
several important aspects of HIV/AIDS care and treatment in a concise,
accessible format; it is not meant to be a comprehensive reference
book. Recommended references and citations are provided for the
reader to be able to access in-depth information on topics that
are particularly important and/or controversial. Appropriate use
of antiretroviral drugs, treatment of opportunistic infections,
symptom management, treatment of concurrent medical conditions,
and other specific interventions to treat HIV disease and its complications
are addressed.
The format
of this guide is designed to provide practical information for the
common questions that arise in the care of patients with HIV infection.
Recognizing the broader array of best practices that contribute
to effective clinical outcomes among patients with a complex array
of service needs, the authors also address patient evaluation, adherence,
mental health, substance abuse, overall clinic management, and other
factors that lead to improved patient outcomes according to the
Chronic Care Model. Last, because the authors recognize the challenges
of maintaining clinical practices in the face of rapidly changing
and ever more complex treatment interventions, a chapter on sources
for updated and in-depth clinical information is provided. Pediatric
HIV/AIDS treatment is not addressed in this book.
Who
is the target audience?
TOP
The target
audience is providers of primary medical care, such as physicians,
physician assistants, and nurse practitioners, who are taking care
of a small but perhaps an increasing number of HIV-infected persons
but who are not experts in HIV care. Parts of this book will also
be useful for nurses, counselors, pharmacists, and others seeking
specific, concise information about the treatment of HIV-infected
persons. Last, specific chapters on clinic management and quality
improvement are relevant for those responsible for the administration
of clinical sites treating patients with HIV/AIDS. Clinicians with
small numbers of patients with HIV/AIDS are encouraged to seek appropriate
expert consultation when complex clinical situations arise. Provider
expertise in HIV care is essential in many treatment decisions.
In fact, patient outcome is correlated with the number of patients
with HIV a provider has treated. For more information, see Suggested
Resources in Chapter 18 on Keeping Up-to-Date: Sources of Information
for the Practicing Clinician.
What
is the purpose of the pocket guide?
TOP
The guide is
a pocket-sized quick reference that provides a summary of all Federal
guidelines dealing with HIV, including antiretroviral therapy (ART),
prevention of opportunistic infections (OIs), management of class
adverse reactions, treatment of tuberculosis (TB) and hepatitis
C (HCV), laboratory testing, prevention after occupational exposure,
and HIV management in pregnancy. It is presented in a format that
is intended for point-of-care decision making: it can be carried
in the clinic and at the bedside to rapidly access needed information
for patient treatment.
The pocket
guide will be updated more frequently than the book to meet rapid
changes in HIV medication options and recommendations.
How
will the guide keep pace with the rapidly changing field of HIV/AIDS
treatment?
TOP
The book details
principles and major recommendations for the treatment of persons
with HIV/AIDS that will remain, for the most part, relevant for
the coming 2 or 3 years. However, the field of HIV treatment is
very fluid, and specific drugs and drug combinations evolve rapidly.
For this reason, such information has been consolidated in the pocket
guide, which will be revised, with updates available in the on-line
version on the HIV/AIDS Bureau (HAB) website. Revisions of the pocket
guide will include new drugs, new treatment guidelines, and new
side effects as well as new drug interactions. In addition to the
pocket guide, information on other useful websites is provided to
help with keeping up-to-date.
- HIV is now
a chronic disease requiring ongoing primary care management.
- The chronic
care model uses coordinated interventions at the clinic, community,
and individual levels.
- A Guide
to Primary Care of People with HIV/AIDS is for primary care providers
who are taking care of a small number of patients with HIV but
who are not experts in HIV care.
- The Pocket
Guide provides easy reference to rapidly changing treatment guidelines
for point-of-care decision making.
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