As humans, we have often confronted epidemics. To fight these diseases, epidemiologists and others start making models and calculating odds based, among other things, on the natural course of the illness. However, in the case of patients who trust the advice of their own physician, medical decision-making is a fundamental responsibility of that physician and occurs at each stage of the diagnostic and therapeutic process.
If we look into the pandemic of Spanish influenza in 1918, we can study the natural history and development of a disease. Application of the scientific method, including hypothesis formulation and data collection, is essential to the process of accepting or rejecting a particular diagnosis. What happens when the course of a disease is in question?
At present, I am looking at a situation that is very different from what many others see. I have been in private practice in the West Village since 2013. I have a considerable number of patients, given the fact that I’m a solo practitioner, and 97% of them are living with HIV. Since the beginning of the COVID-19 pandemic, the majority of them have not been largely affected by it. That is important, taking into consideration that many have compromised immune systems.
Is it that HIV-positive people have a less violent response to coinfection with the new coronavirus, which causes COVID-19, than people without HIV? Maybe. What about HIV-negative people with COVID-19 who are doing OK? Could taking pre-exposure prophylaxis (PrEP) to prevent HIV have something to do with it?
So many New Yorkers are getting sick and dying from COVID-19, yet virtually none of my HIV patients are succumbing. Maybe antiretroviral therapy has something to do with that—I don’t know. One might think my sample population should behave in a similar way to that of the general population or even get sick more frequently and suffer worse outcomes.
I understand that I have a very small point of reference. I would like to be statistically rigorous. I wonder if my colleagues who are taking care of people living with HIV are noticing what I am. (Click here to read a thoughtful analysis by my former associate Paul Bellman, MD, about the implications of what I and other physicians are observing in our HIV-positive patients who have COVID-19.)
I keep asking my patients and myself why this is happening. Even if their experiences with the new coronavirus are different, the answer remains the same: They are all OK—worst case scenario is that they feel like they have a bad cold or have significant flu-like symptoms.
So far, of 200 people in my practice diagnosed with respiratory symptoms, 77 were tested for COVID-19 and only 11 tested positive for it. Thus far, none of my patients who tested positive for COVID-19 met the criteria to go to the hospital.
An important factor to add to this equation is that I know them personally. As a part of my own community, they can tell me whether they are really sick or not. I usually trust my patients to know themselves better than I do. I know their medical histories and I can assess irregularities based on that information.
Why do my patients seem so different from the rest of the population? I have to admit that I’m a bit biased. Because most of my patients are HIV positive, most of them are already trained how to contain, prevent, avoid and/or prophylactically treat a condition.
I say the same thing to all my patients these days: “Stay put, do not go into an emergency room. Should you not feel well, just call me on my cellphone. You will either come to me or I will come to you.”
In a city where medicine has gone corporate and community-based medicine is increasingly rare, the problem is clear: Most people do not have continued health care with somebody they know and can trust—someone they have rapport with, that knows their family’s medical history, whether they have addictions, neurosis, their sexual or eating habits, etc.
People with COVID-19 in New York City have been forced to go to emergency rooms to access a potentially therapeutic combination of hydroxychloroquine, azithromycin and zinc sulfate, which experienced doctors have been using successfully as a short course of therapy to keep patients from severe illness and out of the hospital. This situation is a consequence of policies banning pharmacists from filling prescriptions for these drugs to treat COVID-19 on an outpatient basis.
Unfortunately, a health worker on the frontline who sees a patient first knows nothing about that person and is just following guidelines, such as whether the person has a fever or respiratory symptoms.
At that point, the person has been waiting for a long time in close contact with people that may have the new coronavirus or other transmissible pathogens. By the time the person is seen by a doctor, that person hasn’t had enough liquids, has not eaten properly, is anxious and surrounded by strangers. Whether or not the person had COVID-19, it wouldn’t be irrational to think that the patient is now at risk for it.
The first doctor to see the person is usually inexperienced, and as opposed to a well-seasoned attending physician, that first doctor will act more as a technician, basing decisions more on protocol than on wisdom. Then, the person is finally admitted.
When the person is accepted into the hospital, he or she becomes socially isolated, unable to see loved ones, in a room where dozens of people come in and out not knowing who the heck the person is. This factor in itself would definitely make the person feel and/or actually become sick.
Given the well-known impact of overwhelming stress on illness, could the way people are being handled worsen their medical condition?
I am not by any means underestimating the suffering of the patients and families affected by the new coronavirus. I am also not encouraging people, regardless of their HIV status, to disregard the recommendations by public health officials, such as physical distancing and others. Further, preliminary data on how HIV-positive people are handling COVID-19 is just that—preliminary.
What I hope my own experience shows is that perhaps we need to be more mindful of whether or not our health care facilities need to be constructed and staffed with an approach that is more personalized and beneficial to the patient.
Perhaps we need to better support and utilize physicians such as myself who have frontline clinical experience, personal knowledge of their patients and the trust and rapport that facilitates both prevention and treatment.
Jose M. Lares-Guia, MD, is a physician who leads a private practice in New York City for people living with HIV.