I've been teaching about AIDS for some time now. Along the way I have gotten to know, either in person or through their work, a number of doctors who take care of HIV-positive patients. Perhaps it will sound to you like I am overgeneralizing or stereotyping, but I have come to admire these doctors very much. I found them extremely devoted to their patients, and also heavily dedicated to educating the public about HIV and AIDS. Today, we will see part of a conversation I had with one of those doctors, Dr. James Riddell of the University of Michigan Medical Center. Dr. Riddell is part of a younger generation of doctors, who, during their time practicing medicine did not have to experience the deaths of many of their HIV patients. In Dr. Riddell's professional experience, the death of an AIDS patient is a very rare event. Dr. Riddell graduated from medical school in 1996, just as triple drug, anti-retroviral therapy was reaching patients. Dr. Riddell is an associate professor of internal medicine with a specialization in infectious diseases. At our university hospital, he cares for HIV patients as well as other patients with a wide range of infectious diseases. He also does research on HIV. Studying how the anti-retroviral drugs work, and also seeking to understand where HIV hides in the body, in the reservoirs where it remains inactive until conditions change and it re-emerges. Before we watch the conversation with Dr. Riddel I'd like to remind you of a couple of points because he mentions them frequently. Viral load refers to the number viral particles that are found in a patient's blood. A very high viral load means that the patient's infection is not being well controlled. A low viral load means that the patient's treatment is working. Many patients who are taking medicine have undetectable viral load, which means that it is very low. There is still some virus in those reservoirs hiding in places in the person's body, which is why HIV infections are still not curable. CD4 count is the number of CD4 white blood cells in the patient's blood. These are the cells that are attacked by HIV, and they are very important parts of the immune system. When CD4 counts are low, the body is very vulnerable to infections. High viral loads produce low CD4 counts. One last point. Dr. Riddell talks about getting patients on to triple-drug therapy as quickly as possible. He mentions that this were not the way things were done four or five years ago. In the United States the standard of care has changed. Four of five years ago the rule was test and wait. Treatment was delayed until the CD4 count declined to a certain level or opportunistic infections develop. Now, test and wait has been replaced by test and treat. Early treatment has proven to have better outcomes. In places in the world where the resources are more scarce, test and wait is still the rule, with treatment starting when CD4 counts goes down to a particular level or opportunistic infections arise. I began my conversation with Dr. Riddell by asking him to describe what happens when an HIV positive patient comes to his clinic for the first time. >> Sure. We, we can even back up a little bit to- >> Okay. >> When the patient first has the test done, because it's done in so many different settings. >> Mm-hm. >> So it could be a community based re, setting. It could be in a doctor's office. It could be in the hospital. And so, that's usually where the person may first find out about the test result. What's so important is for the person to find out about the test result verbally. >> Mm-hm. >> Face to face, sort of, communication, which is sometimes where the chain gets, gets broken. >> So that's important both psychologically and for, and to assure follow-up, is that correct? >> [CROSSTALK] Exactly. So linkage to care is so critical at that particular moment when the patient first finds out about the fact that they're HIV infected. >> Do you have some bad stories about that, some people who came in three years later? >> There, yeah, there are. And so, for instance sometimes when the tests are reported, they can even be reported in way that's confusing to a physician. So what, what we've had seen happened is physicians misinterpreting the report that comes in and thinking it's actually negative when it's actually positive. And in that situation, that it can get missed for a period of time. So in our system we set up a sys, system of checks and balances where basically all of the HIV test results come to our clinic for us to review, so we can make sure that anyone who has a positive test gets contacted and went in to care. And so, after that initial sort of information is given to the patient, then it's up to the physician to get them linked into care, somewhere. And that could either be, you know, at University of Michigan, if they're within our system, or if they're with a local physician. But linkage to care is critical at the point. >> Am I right in assuming that the standard of care is to go to an infectious disease specialist? Does that, do any general practitioners care for their HIV patients? >> Yeah, very few these days [LAUGH]. In the past there just simply weren't enough well-trained you know, sort of infectious diseases physicians who, early on in the epidemic, who were caring for these patients. So there were a lot of general medicine doctors who started out specializing in HIV care and some of those physicians continue to, to manage patients with HIV. But these days it's gotten so complicated that really pretty much all patients should mostly be seeing infectious diseases specialist who've even have extra training in, in management of HIV. And so once that patient would then be referred to that clinic, and they would come in and see me and a whole team of people. In our group, we have a physician social workers, a nurse, and specialized medical assistants who all, sort of team up to help take care of the patients. Because there's of, often multiple needs that need to be addressed, especially at that initial visit. >> During the first visit, is a patient going to see each of those team members? >> Sure. So, at each visit in our clinic, we have them initially see a nurse. actually, the first phone call is with a nurse to do an assessment of what symptoms may be present. Is there an urgency to, to the visit? And then, after that's sorted out, an appointment's scheduled. And then, when they first come in, they'll see our nurse MA. The physician and social worker to address all the different needs that they may have. >> So, I'm assuming that the role of the nurse at that point is to basically collect information about what the. What's been happening with that person? >> Yep. >> And the nurse will pass, will pass that information on to you. >> That's right. >> And what happens when the, when the patient walks into the, or you walk into the examining room? >> Yeah, so that's always sort of a unique experience, especially if it's a new diagnosis. Often patients are distraught. It's very difficult sort of time to, to go through. They don't know quite, know what to expect. A lot of patients feel like, you know, once they've been diagnosed with HIV that this is something that's going to lead to shortening of their lifespan. And what I try to do on the first visit is to sort of allay their fears along those lines, and. >> So they're not going to die right away. >> Exactly. >> They're not going to live without sex. >> That's right. >> They might, they will be able to have children. >> That's right. Yup, yup, and so yeah, we can we can address those issues, so. In terms of lifespan depending on the CD4 cell count at the time that the diagnosis is made. If it's closer to the normal range, the lifespan probably is not shortened very much at all with current medication. At least what we know about HIV treatment at the present time. In terms of sexual activity, as long as there's barrier protection used, condom use, which that type of counseling provide that patients can have, you know normal sexual behavior using barrier protection. And we also reinforce the importance of informing partners of HIV infection as well. It's an important part of that as well. And then in terms of having children. That's a question we, we often get. And it sort of depends on the situation. If it's a discordant couple where the, say the man is infected but the female partner is not infected. There are ways to treat the sperm by separating out sperm from semen such that they, and testing for HIV. By molecular methods through a, a sort of a, what would they call, a sperm washing process. And then the female partner can then be inseminated with the washed sperm. And that's been studied extensively in Europe and it's done in the United States and there really haven't been HIV transmissions when that approach is used. Often we get the question well, once my HIV viral load is undetectable, and you know the chances of transmitting HIV are low so can we have children, sort of, the natural way? And we usually counsel against that simply because even though the viral load is undetectable there's still a very small chance that HIV could still be transmitted to the female partner in that situation. >> Somewhere around 2 or 4% chance, is that right? >> So, probably even lower than that. Probably around the order of 1 in 1,000 to 1 in 2,000 chance or even lower. It's hard to quantify. >> I see. >> But very rare. >> So I'm guessing that people take that risk? >> Some people do. [LAUGH] But again, we, we don't counsel people to, to go that route. Because there is that, still that small chance that transmission can occur. >> So there's a lot of counselling that goes on in that first session. >> Mm-hm. >> A lot of response to anxieties. >> Mm-hm. >> What else happens in, in that examining room? >> Yeah, and so, you know, of course initially we take the history and find out what other medical problems the person may have and address the issues of mental health which is very important. anxiety, depression sometimes other mental illness can be coexistent at the time. In addition to just a reactive, you know, grief related to the diagnosis. And then we want to address all the other medical problems the person may have. You know we're seeing people who are diagnosed with HIV at all stages of life. So from young, you know, teenage kids all the way up to older adults. And what we're seeing now with an aging HIV population are these other core morbidities sort of interacting with how we manage HIV infection and so, trying to find out about all the different health problems the person may have. [LAUGH] >> Back to your. They're training in general medicine. >> Exactly. [LAUGH] Yeah, it all plays a role. >> Uh-huh. >> So after we've collected all that information we also discuss issues of substance use, which are also very important and some, again, can sometimes interplay. And we talk about the social situation which is of the, you know, utmost importance because then that will factor in to coping mechanisms for managing let's say, depression, anxiety related to the diagnosis. It'll factor in to how well the person can eventually take medications if, if, depending on their social support network. If they have a strong social support network then often that, that works out much better. So in the back of your mind you're assessing will this person be able to adhere to a drug regimen? >> Exactly, because that's the very first thing in that first visit we're, we're going to assess is A, can the person take the medications, are they willing to take the medications. And then, if so, which regimen are we going to, to use. Because if the newer guidelines that are available basically all patients who are diagnosed with HIV are offered medication, nowadays. Which is a, a shift from just you know, four or five years ago. When we used to not take that approach. And then is there lab work that you order at that point in order to- >> Mm-hm. >> Pinpoint the the particular drugs that you want to use? >> Yep, absolutely. And so even before lab work is a physical exam what we, that we'll go through. And some of the things we're looking for there are different types of opportunistic infe, you know, evidence of opportunistic infections or other sexually transmitted infections. Particularly HPV, which causes warts, genital warts, rectal warts. We see a very high incidence of rectal cancers associated with HIV and, and HPV. So we're looking for things in the physical exam that would suggest maybe the state of their immune function and then we would go to lab testing. So there we're looking at the CD4 count, HIV viral load to assess sort of where they are in their stage of HIV infection. And then getting to your point about treatment we're checking an HIV resistance genotype test to look to see if their transmitted drug resistance mutations. >> That's a very exciting part part of it, the genotyping of the HIV. >> Yeah. And so what, what that test does is it's sequencing the, a couple of different genes, the reverse transcriptase gene and the protease gene. And then we're looking for mutations within those genes, so it'll help predict which medications will work and which ones won't. And about 15% of patients will have some transmitted drug resistance and so it's something we do routinely know. >> That's a high number. >> It is. [LAUGH] It is a high number. >> And that's because they've been infected by a person who has already developed resistance to at least one drug. >> That's right. And so it may be that that, that person could have been infected with a, a virus that had transmitted drug resistance, or it could be somebody who was taking medication intermittently stopped taking medication, developed resistance and then passed that virus along. >> So if I'm your patient for the, and, and I do my first visit today, and go through the procedure that you're talking about, how long before you write the prescription and I go on the, on the medication? >> It really varies from patient to patient and it's individualized. So for somebody who comes in who has a good social support network is, has maybe taken medications before and, and we get a good feel that the person is motivated to take the medication and. We get a good sense that the person will be able to adhere to the regimen and not miss doses. We could start right away on that, that first visit and often that, that's the case. >> And what about the other kind of case? Suppose I come in, you find that I have a a, a, a psychological disorder- >> Mm-hm. >> Which may interfere. I have a poor social support network, wa, what happens to me then? >> Yeah, so some of it depends on the CD4+ count and viral load and wa, what stage of infection is present, so. And somebody who is well-maintained and has a pretty good CD4 cell count and they're not at risk for developing complications right away, we may wait until we address all those issues. Address the mental illness. Making sure they're getting tied into psychiatry. Getting on the correct medications there. We see the counseling that they need. Maybe address some of the social support network issues. And, sometimes we'll even a, a, a patient practice taking a vitamin pill everyday, and, and, for, for a period of a month. Just to get used to what it's like to take, take a medication everyday, and to see if they'll, they'll be able to adhere. >> I'm guessing that the reason that you don't put them on medication right away with these other problems is that if they don't adhere to that first round of medication, then they'll dev, they may well develop resistance, and it will be harder to treat them in the future. Is that correct? >> Yeah, that's correct. And so, generally patients, there's a limited number of medications [LAUGH] we have available, and so the more medications you develop resistance to the less effective treatments are sort of, available on down the line and then it also may limit the simplicity of treatment. So for instance we'll often start off with a treatment that's one pill once a day. Very easy to take, and then if you're to develop a resistance to one part of that medication then that one pill once a day option is, is taken away, and, and it often leads to taking multiple pills per day or, or multiple tablets, multiple times per day. So that makes it more difficult to treat in that way as well. Or it may be medications that are hard to tolerate for instance. So really getting that first regiment right [LAUGH] and getting it started at the right time for the right patient is so critically important. Because often that first regiment is, is the most important. >> Does the team that you've described have a conference about each patient? >> Sometimes we do. So particularly complicated [LAUGH] patients where we really need to have a multidisciplinary approach that involves social work. More outside agencies nursing we'll, we'll get together and talk. Or patients who have particularly difficult resistant genotype tests that require some sort of thought in terms of which medications are going to work the best. we'll, we'll have conferences to with you know, some of the other physicians, to discuss what would be the best approach. >> The easy patients you may not need it. >> Exactly. >> Uh-huh. >> Right. That's right. >> And how frequently will a patient come back to see you? >> Yeah, so after the initial visit, say we've started medication, we'll usually have them come back in about a month. And at that point, we'll expect to see the HIV viral load dropping by about 1 log base 10, so if they start out at 100,000, you'd expected it to be around 10,000 at that next visit if they're responding appropriately. The other thing we'll do is review adherence and adverse effects related to the medicine. Even before that, I'll back track a little bit. About two weeks after the visit, our nurse will give the patient a call to make sure they were able to get the medication. They understand how to take it. Make sure they aren't having any initial side effects. And at that one month visit we'll follow up and make sure that they're responding appropriately. And then check lab tests to make sure that there's no adverse affects, for instance liver enzyme ovations or cranial ovation, that type of thing. >> The big issue I take it is adherence. In your practice here at the university medical center, how often does that happen or how, and how often does it just go swimmingly? >> It really varies [LAUGH] from patient to patient. So I would say, again with patients who have a strong support system and are motivated and that will come to follow-up clinic visits on a regular basis things go very well. I've had patients, I've been doing this for almost 15 years. I've had patients who've done just fine and over that period never had problems with resistance to some, or even to the same regiment they started many years ago and are doing just fine. Others where they're issues of adherence for instance, mostly related to social support network, or substance abuse or mental illness who have trouble, or just by choice, or can't, don't want to take the medicine, or can't tolerate the medicine. There's a subset of, of patients where they just cannot take any medicine, seemingly, because of nausea, vomiting, GI side effects. For a variety of reasons and those patients don't do as well and they end up developing complications related to AIDS over time. >> I've heard people say, every time I take a pill it reminds me that I have AIDS or that I'm HIV positive and every once in awhile I just can't stand it and I stop taking it for a few days. >> Yep. >> I take a little holiday. >> Mm-hm. Do you see much of that? >> Occasionally. Not quite as much now as we used to. And the reason for that is that the medications are so much easier to take now. There are fewer side effects. The pill burden is less. And so, we're seeing less of that. But early on, when I first started doing this, where the patients had to take more tablets, more side effects. There's more of that sort of medication fatigue or you know, pill fatigue that people would experience and then that would just stop for periods of time. Which lead to more resistance. Which is something we see much, much less now then we use to patients who are failing therapy.
