AIDS--no longer a death sentence, still a challenge.The human immunodeficiency virus human immunodeficiency virus n. HIV. Human immunodeficiency virus (HIV) A transmissible retrovirus that causes AIDS in humans. (HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. ) is now found in every country of the world, infecting 56 million persons worldwide. (1) Twenty million persons have died as a result of HIV alone. In the United States 1.1 million persons are infected with HIV. Before the advent of antiretroviral drugs Antiretroviral Drugs Definition Antiretroviral drugs inhibit the reproduction of retroviruses—viruses composed of RNA rather than DNA. The best known of this group is HIV, human immunodeficiency virus, the causative agent of AIDS. in 1987 most patients with AIDS eventually succumbed to opportunistic infections Opportunistic infections Infections that cause a disease only when the host's immune system is impaired. The classic opportunistic infection never leads to disease in the normal host. such as Pneumocystis carinii pneumocystis carinii: see pneumonia. and cytomegalovirus cytomegalovirus (sī'təmĕg'əlōvī`rəs), member of the herpesvirus family that can cause serious complications in persons with weakened immune systems. , malignancies such as lymphoma or Kaposi sarcoma Kaposi sarcoma Usually lethal cancer appearing as red-purple or blue-brown spots on the skin and other organs. It has been linked to one of the herpes viruses, and there is considerable debate about how it should be classified. , or the direct effects of the virus on the central nervous system and other organs. The average lifespan of the untreated AIDS patient was about 10 years. The advent of retroviral therapy in 1987 has dramatically reduced the mortality rate from AIDS. In the three years following the introduction of highly active antiretroviral therapy Noun 1. highly active antiretroviral therapy - a combination of protease inhibitors taken with reverse transcriptase inhibitors; used in treating AIDS and HIV drug cocktail, HAART (HAART HAART highly active antiretroviral therapy. HAART Highly active antiretroviral therapy, triple combination therapy AIDS The concurrent administration of 2 nucleoside reverse transcriptase inhibitors–eg, AZT and 3TC, and a protease ), AIDS-related mortality and hospitalizations decreased 60 to 80%. (2) However, there is still not a cure for AIDS. HIV, at least in the United States, has changed from a terminal illness to a chronic disease requiring daily medication for survival. With increased survival in the AIDS patient, the prevalence of HIV in the population at large has increased, including among the elderly. (3) As a result, an increasing proportion of patients with HIV and AIDS will require nursing homes and other long-term care facilities. Thus a myriad of new problems related to the care of AIDS patients will be presented to such facilities. Universal precautions in the handling of body fluids will need to be stressed. Familiarity with antiretroviral drugs and other medications such as prophylactic antibiotics will be necessary. In spite of the benefits of antiretrovirals, some patients continue to develop AIDS-related complications such as mycobacterium avium complex Mycobacterium avium complex (MAC) is a group of genetically-related bacteria belonging to the genus Mycobacterium. It includes Mycobacterium avium subspecies avium (MAA), Mycobacterium avium subspecies hominis (MAH), and (MAC) and tuberculosis, neurologic impairment from HIV neuropathy and HIV dementia, and vacuolar myelopathy of the spinal cord. (4) These disorders may produce chronic disability and require special forms of rehabilitation. HIV is a stigmatized disease. Other patients in long-term facilities may be reluctant to share rooms with HIV patients. Rehabilitation and finding employment may be especially difficult for these patients. (5,6) The reluctance of some patients to share a facility with AIDS patients may encourage chronic care facilities to exclude HIV patients for financial reasons. The increasing prevalence of AIDS as a chronic disease in the general population, combined with the increased numbers of "baby boomers" reaching the age where chronic care is required, challenges the capacities of long-term care nursing facilities. Are these facilities up to the challenge? Pearson and Hueston's article in this issue of the Southern Medical Journal, "Treatment of HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome in the Nursing Home: Variations in Rural and Urban Long-Term Care Settings" (7) suggests that they are not. These authors used the 1999 National Nursing Home Survey (8) to determine which nursing homes in the United States provided specialty HIV/AIDS services. Of 1,423 nursing homes, less than 1% provided specialty HIV/AIDS services. The proportion of adults with AIDS is highest in the rural South. Therefore, the presence of long-term care facilities that care for AIDS patients in rural communities is of special interest. Rural long-term care facilities were more likely to be smaller and have greater dependence on patients funded only by Medicaid. Larger nursing homes were more likely to provide HIV/AIDS specialty services. The authors speculate that the small percentage of nursing homes providing HIV/AIDS services might be explained by lack of any financial incentive for the facility to provide these services. Elderly patients with HIV might be receiving special care in community settings such as home care or in specialty centers rather than in more traditional settings. The finding that smaller long-term care facilities were significantly less likely to offer specialized HIV/AIDS services, although possibly not a problem now, might portend por·tend tr.v. por·tend·ed, por·tend·ing, por·tends 1. To serve as an omen or a warning of; presage: black clouds that portend a storm. 2. that in the future, there will be a shortage of facilities offering special AIDS-related services in precisely the rural areas where the AIDS population is the highest. This important study suggests that in the future our ability to care for HIV patients in long-term care facilities may be taxed to the extreme. Further studies of the attitudes of patients without HIV and their families toward long-term care facilities that treat AIDS patients should be performed. Studies of the financial incentives for the care of AIDS patients and their relationship to the development of specialized services for the care of AIDS patients are indicated. Accepted December 16, 2003. Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9704-0329 Please see "Treatment of HIV/AIDS in the Nursing Home: Variations in Rural and Urban Long-term Care Settings" on page 338 of this issue. References 1. Adler MW. ABC ABC in full American Broadcasting Co. Major U.S. television network. It began when the expanding national radio network NBC split into the separate Red and Blue networks in 1928. of AIDS: Development of an Epidemic BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 2001;322:1226. 2. Mocroft A, Ledergerber B, Katlama C, et al. Decline in the AIDS and Death Rates in the Eurosida Study: An Observational Study. Lancet 2003;362:22. 3. Gordon SM, Thompson S. The changing epidemiology of human immunodeficiency virus in older persons. J Am Geriatr Soc 1995;43:7-9. 4. Tindall B, Barker S, Donovan B et al. Characterization of the acute clinical illness associated with human immunodeficiency virus infection. Arch Intern Med 1988;148:945. 5. Selwyn PA, Goulet JL, Molde S, et al. HIV as a chronic disease: implications for long-term care at an AIDS dedicated skilled nursing facility skilled nursing facility n. Abbr. SNF An establishment that houses chronically ill, usually elderly patients, and provides long-term nursing care, rehabilitation, and other services. . J Urban Health 2000;77:187-203. 6. Levinson SF and Fine SM. Rehabilitation of the Individual with Human Immunodeficiency Virus, in Delisa J and Gans B (eds): Rehabilitation Medicine: Principles and Practice Philadelphia, Lippincott-Raven, 1998, ed 3, pp 1319-1335. 7. Pearson WS and Hueston WJ. Treatment of HIV/AIDS in the nursing home: variations in rural and urban long-term care settings. South Med J 2004;97:338-341. 8. Jones A. The National Nursing Home Survey: 1999 summary. National Center for Health Statistics National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC), which is part of the United States Department of Health and Human Services. NCHS is the United States' principal health statistics agency. . Vital Health Statistics 2002;13(152). James K. Schmitt, MD, and Charles P. Stuckey, MD From the Department of Internal Medicine, Hunter Holmes McGuire Department of Veterans Affairs Medical Center, Richmond, VA Reprint requests to James K. Schmitt, MD, VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249. |
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