to the editor: In the “Medicine and Society” piece titled “The Changing Spectrum of HIV Care,”¹ Dr. Reyes and colleagues summarize the challenges of the changes facing physicians who are treating patients living with human immunodeficiency virus (HIV) infection. Family physicians and other primary care providers are well suited and situated to treat these patients who, in addition to their HIV infection, must deal with other stressful life events that may require the services of a caring physician.

However, the issue of clinical experience cannot be overemphasized. Developing the “art” of selecting an appropriate treatment regimen from the complex and ever-expanding range of antiretroviral medications that matches the particular virus's resistance pattern and meets the lifestyle of the patient is challenging and time consuming. Special skills are required of physicians to determine “the regimen” (up to 23 tablets per day) that best fits with the patient's lifestyle and is one that the patient can follow. Physicians must then monitor and coach the patient into compliance with a difficult regimen.

The “guidelines”² represent starting points that are based on current knowledge and seem to change on a daily basis. Thus, maintaining up-to-date information requires substantial effort by physicians. Studies have demonstrated that HIV-infected patients have better outcomes if they receive care from a physician who regularly manages and treats such patients. Family physicians who practice in rural or other areas with a low prevalence of HIV infection face significant challenges. It is advisable for these physicians to establish a relationship with an HIV-experienced physician who is available for regular consultation.

in reply: We agree with Mr. Wennberg that clinical experience with human immunodeficiency virus (HIV) cannot be overemphasized in attempting to assure quality care. It appears, however, that much work remains to be done before all vulnerable populations living with HIV infection (particularly minorities, women and uninsured patients) receive even standard care.¹ The best study of HIV care delivery to-date indicates that at least one third of HIV-infected persons do not see a physician on a regular basis for care.²

As the epidemic continues in rural and urban populations, innovative strategies continue to be devised to address quality of care issues. The National AIDS Education and Training Centers of the Health Resources and Services Administration (HRSA) has devised a Targeted Training Plan that addresses the needs of physicians who have a high volume, intermediate volume or low volume of HIV-infected patients in their practice. For example, for high-volume physicians (those with more than 50 HIV-infected patients in their practice), the program emphasizes content directed at complex antiretroviral therapy regimens and salvage therapy; for low-volume physicians (those with less than five HIV-infected patients in their practice), the program emphasizes risk assessment, case identification and use of referral networks and other resources. Information about these local and regional training programs is available at the HRSA Web site (http://www.hrsa.gov/).

In an ideal world, all physicians who see a low volume of HIV-infected patients would have access to expert HIV consultation; however, this is not the reality of the practice landsape. HRSA, in collaboration with the American Academy of Family Physicians, has also funded the National HIV Telephone Consultation Service (Warmline). The Warmline provides free expert HIV consultation to family physicians and other health care providers during weekdays at 800-933-3413. Since 1991, the Warmline has provided nearly 30,000 consultations to a relatively equal distribution of physicians who have a high, intermediate or low volume of HIV-infected patients in their practice. Of key importance is the Warmline's role in supporting family physicians and other health care providers, who, although they might manage only a few HIV-infected patients, remain the principle source of HIV care in their communities.