HIV management returning to primary care providers.

A 32-year old uninsured woman, living in a rural town in the Deep South, presents to the emergency room at a local hospital with complaints of cough and fever. She is diagnosed with pneumonia and given a prescription for an antibiotic. It takes a few days to raise the money for the prescription but she eventually fills it and improves with treatment. Over the next several months, she goes to three different free-care clinics for vaginal yeast infections. One year after the initial episode of pneumonia, she returns to the same hospital with gradually increasing shortness of breath, a non-productive cough, and a low-grade fever. Her chest x-ray reveals a bilateral interstitial pattern and her PaO2 [partial pressure of oxygen in arterial blood] is 52. She is admitted to the hospital and clinically worsens over the next 24 hours, requiring intubation. Bronchoscopy reveals the patient has Pneumocystis jiroveci pneumonia and the patient is found to be HIV-infected. Her CD4 lymphocyte count is 34 cells/hpf. This scenario is intended to represent the fact that patients with undiagnosed HIV infection frequently access the health care system several times before they are tested for HIV, resulting in late diagnosis and an AIDS classification (CD4 count 200). It is estimated that over 1,200,000 people in the United States are living with HIV infection; despite extensive efforts for primary prevention, the CDC estimates there are 56,300 new infections annually.1 The efficacy of HIV treatment has dramatically improved since the mid-1990s, with the introduction of highly active antiretroviral therapy (HAART) resulting in a decrease in the incidence of AIDS-related deaths. Consequently, a steady number of new infections coupled with a decrease in mortality rates results in an increase in the total number of people living with HIV each year. In 2006, the CDC released its Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings (http://www.cdc.gov/mmwr /preview/mmwrhtml/rr5514a1.htm). In this document, the CDC encourages the routinization of HIV screening/testing for everyone in the U.S. between the ages of 13 to 64 years. When patients initially enter a health care system, they should be asked as part