A New Era of HIV Infection: Treating A Changing Population Of Patients In A Rural Community

(From left) Dr. Rohit Talwani and Pat Derajtys discuss treatment options with one of their patients in Sumter.

The patient waiting for her appointment at Sumter’s Family Health Center is a woman is her mid-50’s. Not unlike many patients today infected with the HIV virus, she has only been involved in heterosexual relationships. The faces of AIDS and its precursor of HIV infection are changing, and that’s no exception for the residents of Sumter County and the rural counties surrounding it.

More than half of the 200 low-income patients that nurse practitioner Pat Derajtys sees at the community health facility are women, with a disproportionate number of them African American. Derajtys and Dr. Rohit Talwani, an infectious disease specialist in the Department of Internal Medicine, provide services to HIV/AIDS patients three times a month under the umbrella of the Ryan White Clinic, a federally-funded program managed by the USC School of Medicine.

A disturbing lack of awareness is common among the patients Derajtys treats. “There are still too many people out in rural areas who do not realize that they are at risk, especially women. A man comes along and says, ‘You are the love of my life,’ and the woman doesn’t question his sexual history,” she said. With homosexuality still an unaccepted practice in small Southern towns, she explained that men often carry on sexual relationships with other men, unbeknownst to their female partners. Consequently, heterosexual spread of the disease is on the rise, with Sumter consistently ranking among the top three counties in South Carolina for prevalence of HIV infection.

Thanks to the development of AZT and other medications currently used in treatment, the prognosis for patients with HIV infection has improved dramatically since the School of Medicine established their relationship with the Family Health Center in 1995. “In the past we were basically getting people ready to die. It’s a whole different ballgame today. As long as patients are consistent in taking their medications they can do extremely well,” said Derajtys.

Treating the disease is a complex job, one that’s frequently compounded in Derajtys’ patients by such issues as unemployment, poverty, and substance abuse. “A lot of times the HIV is just piled onto all these other problems they have,” she said. Fortunately, services available for HIV/AIDS patients through the Family Health Center have expanded over the course of the last ten years. In addition to a physician and nurse practitioner in Sumter who care for patients between visits from Dr. Talwani and Derajtys, resources include a full-time social worker, a substance abuse counselor and a perinatal case manager, who follows pregnant women until the birth of their babies.

Reducing the risk of transmitting the disease is an important component of Derajtys’ work. While educational efforts in the past have been targeted to groups at risk for the infection, such as gay men and drug abusers, today’s focus is on patients who are already HIV-positive. “Are they in relationships right now? Have they disclosed their illness to their partners? Where are they in terms of their practices that may put other people at risk? These are the type of questions that need to be discussed with patients’ health care providers,” she said.

South Carolina HIV/AIDS Clinical Training Center

Patients with HIV infection aren’t the only ones who benefit from education on the disease. A year ago the Department of Internal Medicine took on the management of the S.C. HIV/AIDS Clinical Training Center. The statewide program is devoted to providing health care providers with the knowledge and skills necessary to treat patients with HIV infection who have difficulty in affording or accessing treatment. “The care changes so rapidly, with new patterns of resistance and new combinations of medicines,” said Derajtys. “A community doctor who is operating under what he knew five years ago can’t serve a patient as well as someone who takes care of HIV patients all the time. He or she should have opportunities for updated training,” she said. The center does just that in a variety of ways, from phone consultations on individual patients, to a statewide annual conference, to practical on-site training at local clinics to clinical preceptorships at Columbia’s Ryan White Clinic.

“Some physicians struggle with caring for these patients and others do a very good job with it. Unfortunately, many times physicians in rural communities just turn patients over to an infectious disease specialist because it’s a little more than they can get comfortable with,” said Derajtys. The center’s objectives include changing this comfort level and increasing the number of health professionals caring for HIV/AIDS patients.

Just learning what resources are available can be helpful to physicians and other health care professionals throughout South Carolina. Others have taken advantage of the structured workshops, preceptorship opportunities, and technical assistance available through the training center, which can be adapted to meet particular needs. “Obviously you can sit people down in a classroom and tell them how to take care of HIV patients. If their schedule permits, we’ve offered to see patients with them at their practice. Or we may say, ‘Tell me about your patients and how you treat them and I’ll give you suggestions.’ There are any number of options,” Derajtys said.

Reprinted from Connections newsletter, May 2005

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