HIV: A Physician’s Perspective

AS CHIEF OF service at El Rio Special Immunology Associates (SIA) in Tucson, Ariz., Dr. J. Kevin Carmichael oversees the care of 1,250 HIV-infected patients and personally attends to almost 300. He also provides clinical support for area physicians dealing with HIV.

BSTQ: Tell us about your early work with HIV/AIDS.

Dr. Carmichael: I was in medical school from 1982 to 1986 in Miami, Fla., when HIV was first coming along and many doctors referred to it as “gay-related immune deficiency.”As the epidemic unfolded, we saw more and more women and children infected. It was common back then to have kids living in the hospital because their parents had died and no one would adopt them because they were going to die too. It was a difficult time.

BSTQ: How have things changed?

Dr. Carmichael: In the ’80s and early ’90s, our work was largely about caring for dying people. Since 1996, it’s been more about helping people living with HIV attain meaningful and healthy lives. Doctors who are getting into HIV treatment today have a different perspective. When I started, there were times when, no matter how much you wanted to, there was simply nothing you could do. People were really sick, and you could offer little hope.

BSTQ: How has HIV treatment evolved?

Dr. Carmichael: I believe the evolution of HIV treatment is the greatest medical success story in my lifetime. In 1995, 14 out of every 100 patients in our clinic died. As of this year, it is one out of 100. Complicated multipill regimens have been replaced by more combination formulations dosed once or twice daily. Highly Active Antiretroviral Therapy (HAART) has sufficient potency [so] that viral control is common and the development of viral resistance is significantly reduced. When you look at the majority of people who die from HIV today, it is often because they are not on treatment.

BSTQ: How much does HIV care cost?

Dr. Carmichael: On average, medications run $25,000 to $30,000 per year, plus the cost of lab work to monitor care. The largest expense in HIV care today is medication, compared to the old days when it was in-hospital care.

BSTQ: How do you encourage patient compliance?

Dr. Carmichael: We use the term adherence rather than compliance; it means the patient is making a decision to do something as opposed to doing something I’m asking them to do. My job is not to shake my finger and make you take your pills. My job is to convince you [that] the plan you and I came up with is in your best interest. The HIV virus replicates very rapidly, and if people don’t take their medications on a consistent basis, the virus replicates in the presence of low levels of drugs, and drug-resistant virus results. We understand human nature; no one will be perfect. We ask patients to aim for 95 percent adherence and, in fact, the majority of our patients have undetectable viral loads.

BSTQ: What advice do you have for clinicians?

Dr. Carmichael: I think the biggest issue for general practitioners is not doing enough HIV testing. The current CDC [Centers for Disease Control and Prevention] guideline recommends all people ages 13 to 65 be checked annually, but testing is rarely offered because doctors are busy, have many issues to address, and can be reluctant to raise HIV testing for fear of offending patients. As physicians, I think we have an obligation to lead the discussion. I’d like to see us move toward a time when HIV testing is part of routine medical care.