Some doctors still wary of AIDS cases

January 24, 1994|By Holly Selby | Holly Selby,Staff Writer

For months Gwen Green had recurring infections, swollen glands and chronic fatigue. Her youngest daughter suffered from several bouts of pneumonia coupled with alarmingly high fevers.

But not until Ms. Green applied for a life insurance policy did someone suggest that she be tested for HIV, the virus that causes AIDS.

Now, as the Baltimore woman looks back on her illnesses, now that she knows that she has acquired immune deficiency syndrome and that her youngest daughter has the human immunodeficiency virus, she says, "I had all the symptoms all along, but I never thought I was at risk, and I know my doctor never dreamed it."

Thirteen years after the onset of the AIDS epidemic, some family doctors are still reluctant to suggest testing for HIV, federal public health officials say. And, if patients test positive for the virus, some physicians hastily refer them to infectious-disease experts.

One result is that many patients do not get early care for HIV. Another is that clinics and hospitals nationwide that specialize in treating those with the virus as well as those with fully developed AIDS are becoming overburdened.

To help combat this, the U.S. Public Health Service released guidelines last week aimed at encouraging primary-care physicians to treat patients who have the AIDS virus.

The 196-page "clinical practice guideline" includes advice ranging from how frequently blood tests should be administered to when anti-viral drugs are most useful. It also includes segments on counseling and informing patients about disadvantages and advantages of disclosing their HIV status.

"A number of individuals with HIV aren't even being asked the relevant questions about their lives, about risk," said Dr. Philip R. Lee, assistant secretary for health. "Many physicians don't even think about it in relation to women and children."

More than 204,000 Americans -- including 4,417 Marylanders -- have died of AIDS since 1981, and at least 1 million U.S. citizens have HIV, according to the federal Centers for Disease Control and Prevention.

But only half of the Americans who are infected with the deadly virus know they have it, Dr. Lee said.

"AIDS is moving from the coasts of America to the Midlands and is beginning to appear in every hamlet and town," said Dr. Roy Schwarz, senior vice president of the American Medical Association, which approved the guidelines. "All doctors will see it and they have to be able to diagnose it. We don't have enough AIDS experts to take care of all these people."

Disease intimidates

Many physicians feel intimidated by a complex disease in which advances and changes in treatment occur rapidly and frequently, said Dr. John Bartlett, director of the infectious-disease division at the Johns Hopkins Medical Institutions.

At the onset of the epidemic, patients were immediately referred to infectious-disease experts, creating a feeling within the medical community that treatment of HIV and AIDS always required some kind of specialist, he said. Doctors at clinics and private physicians who accepted HIV patients became known in their communities as "AIDS doctors."

For those patients who do not have easy access to clinics such as Johns Hopkins' Moore Clinic or the Chase-Brexton Clinic in Baltimore, quality and aggressiveness of treatment can be uneven, Dr. Bartlett said.

Treatment easier now

"There tends to be a cadre of AIDS physicians who are tapped into the network of information and who go to all the meetings, but the information doesn't always reach the average practicing physician who may nonetheless be seeing people with AIDS," said Dr. Bartlett, who for several years has prepared HIV-treatment guidelines for distribution by Maryland health authorities.

The virus is easier for a family physician to manage now because more is known about the virus, and people with HIV may not develop full-blown AIDS for many years, said Dr. Alfred Saah, an epidemiologist at the Johns Hopkins School of Hygiene and Public Health.

"HIV doesn't need a specialist," he said. "It is perfectly manageable like hypertension or diabetes."

Ignorance, however, is not the only reason that some doctors are reluctant to treat AIDS patients. As a sexually transmitted and fatal disease first associated with homosexuals, then intravenous drug users, AIDS bears a heavy and complex social stigma.

Many physicians -- as did much of society -- initially viewed AIDS as a disease that spread only in particular segments of the population -- first gay men, then drug users, said Dr. Leonardo Ortega, executive director of Baltimore's Health Education Resource Organization (HERO). "It was seen as a stigma to be among the gay community even as a doctor," he said.

For years, Dr. Ortega said, many doctors referred AIDS cases to him simply because he was gay.

"As an openly gay man, I was seen as a person who could deal with [AIDS patients] better. And, yes, maybe I have a greater interest. But, as a doctor, a physician, they have a responsibility," he said.

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