The AIDS epidemic: neglected issues.

Abstract

The emergence and spread of the AIDS epidemic is beginning to have a profound impact on the practice of clinical medicine in the United States. Although many of the changes are obvious, others are subtle and have not been adequately addressed. Dealing with some of these issues may improve the care given to patients with this tragic disease. During the early years of the epidemic, cases of AIDS were heavily concentrated in a few major metropolitan areas and seen in a few large medical centers within those areas. The syndrome was a novelty. A handful of infectious disease (ID) clinicians and oncologists became interested in the disease and attracted referrals. However, the explosion of cases has changed this situation. Now, virtually any medical center that is large enough to support an ID clinician or oncologist is seeing cases of AIDS. ID clinicians in some cities and suburbs have been overwhelmed. In addition, because of the extent and chronicity of AIDS, many institutions are less anxious to assume primary responsibility for all of these patients. As the novelty of the disease has worn off, so has the clinical interest of many academic physicians. Recent projections suggest that the number of cases of AIDS and human immunodeficiency virus (HlV)-associated diseases will rise at least fivefold in the next five years [1,2]. The investigators predict that most of these cases will occur outside of New York and California. As the disease becomes endemic in other areas, it is not clear who will act as primary care physicians for these patients (i.e., internists, oncologists, or ID clinicians). Of greater concern is the tremendous cohort of asymptomatic HIV-positive patients. Current literature downplays the percentage of these patients that will go on to develop clinical disease, but data suggest that no HIV-positive patients clear the virus. Most of these HIV-positive patients (M.5 million in the United