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Gordon Nary
The International Association of Physicians in AIDS Care

March, 1997

In January I presented a paper on the use and misuse of clinical guidelines for the management of HIV disease at the Disease Management Congress in San Francisco. Our association is concerned that the lack of expertise in combination antiretroviral therapy by some physicians may be contributing to the continuing breakthroughs in viremia-and that this lack of expertise may contribute to the misuse of clinical guidelines by such physicians.

Some physicians and managed care organizations can use guidelines in the same way that a drunk uses a lamppost-either for support or illumination. When clinical guidelines for HIV disease are used to support a clinical treatment decision, a physician could do harm to his or her patient. The protean dynamics of HIV management can make guidelines quickly outdated.

At best, clinical guidelines for HIV disease management are Proustian vignettes of how a patient may have been appropriately treated at a specific moment of time past. Unfortunately, today's standard of care for HIV disease may be tomorrow's malpractice suit. An excellent example of this is the current (as of January 30) guidelines for antiretroviral treatment on the US Agency for Health Care Policy and Research's Web site, which advocates ZDV monotherapy. While data supporting such therapy are obviously obsolete, physicians with little or no experience in HIV disease management who rely on this Web site could use such outdated guidelines to support a clinical decision that should be malpractice when other options for combination therapy are available.

As someone in the audience pointed out to me after my presentation, the pharmaceutical industry, along with government and professional associations, may be somewhat responsible for shunting people with HIV to physicians who are ill-requipped to manage this disease. The pharmaceutical industry justifiably invested millions of dollars in the 1980s to convince physicians who were reluctant to care for people with HIV disease to take on this challenge. Many physicians subsequently agreed to care for HIV/AIDS patients because they perceived that the management of the early and middle stages of HIV disease was not too complicated. But now that the complexities of when to start therapy, which agents to use, and when to switch therapy often require the skills of an HIV specialist, many of these physicians are not updated on the rapidly changing dynamics of antiviral treatment.

Many pharmaceutical manufacturers prefer to invest in the medical education of only those physicians with relatively sizable HIV practices. It is not cost-effective to provide to physicians with only a few patients the same level of education as is provided to physicians with larger HIV practices in the major epicenters. And while the federal government is also in the HIV clinical guidelines business, the commitment to universal distribution and regular updates of such guidelines have not as yet been realized.

If physicians who use obsolete clinical guidelines do harm to their patients, then those of us whose responsibility it is to publish and distribute such guidelines must share the responsibility for such harm. Some might question whether it is more harmful to develop clinical guidelines and not keep them updated than not to develop guidelines at all.

©1997, Medical Publications Corporation

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