The blog is about health and gives useful information on health and disease.

AIDS physicians are physicians who devote most of their time to caring for people with HIV infection. By strict definition of the word specialist there is no such person as an “AIDS specialist”: rather, some physicians simply adopt the treatment of AIDS and HIV infection as a special interest.

A little background on what makes a specialist:

Physicians practice in a variety of specialties, including family practice, pediatrics, internal medicine, surgery, and obstetrics and gynecology. Becoming a physician requires graduating from medical school, doing postgraduate training as a resident, passing standard tests, and getting a license through the state licensing board. By law, a physician requires a license to practice medicine. The type of postgraduate training determines the specialty.

Becoming a certified specialist requires certification by a professional specialty board within the American Board of Medical Specialties. Certification requires postgraduate training for a specified number of years in an approved training program, followed by passing an examination in the specialty called a board examination. To be certified as a cardiologist, for example, the physician must take three years of postgraduate training in internal medicine, then pass the board examinations to be certified as a specialist in internal medicine, then take three additional years of postgraduate training in cardiology, and then pass the board examinations in cardiology to be certified in cardiology. Any physician can claim to be a cardiologist, but only those who satisfy these requirements can call themselves board-certified cardiologists.

There are no recognized accredited training programs for specializing in HIV infection and no board examinations to certify competence in treatment of HIV infection. This means there is no medical specialty in HIV infection, and there is not likely be one in the foreseeable future. Instead, physicians with different kinds of training and with different specialties have adopted AIDS as a special interest. To repeat, these are physicians informally called AIDS physicians.

The specialty that has provided most of the AIDS physicians is infectious diseases, which, like cardiology, is a subspecialty of internal medicine. Specialists in infectious diseases become AIDS physicians because HIV infection is an infectious disease, and because most of the

opportunistic infections are those commonly encountered during infectious disease training. Some specialists in infectious diseases primarily treat people with HIV infection; some treat people with other infectious diseases plus people with HIV infection. Most infectious disease specialists have the appropriate expertise to treat people with HIV infection.

Other medical specialties also supply AIDS physicians. Some specialists treat AIDS because of the nature of their specialties: oncology, pulmonary medicine, dermatology. Others, like gay physicians, treat AIDS for more personal reasons.

AIDS physicians keep current with this fast-moving field by attending medical meetings dealing with HIV infection and by subscribing to several of the forty to sixty medical journals devoted to HIV infection. Their practices may be limited almost exclusively to people with HIV infection, and they are themselves often leaders in the community in social, medical, and political issues that relate to HIV infection.

Treatment of HIV infection has attracted some of the country’s most competent and compassionate physicians. It has also attracted some physicians who promote what many other physicians would consider ill-advised or even risky treatments. Remember, any physician can claim to be an AIDS physician, and no reputable professional group has certification requirements by which to substantiate the claim.

Unfortunately, at present, the numbers of AIDS physicians are inadequate to serve the increasing numbers of people with HIV infection. As a result, many people with HIV infection receive medical care from primary care physicians who call on AIDS physicians to help with the more difficult complications of the disease. This plan for medical care will work well as long as the supply of physicians for both early care and later complications keeps pace with the epidemic.

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Jvy’s mother and sister had breast cancer, so she was reluctant to take HRT. She is 60 now, and when she was perimenopausal a decade ago, her doctor warned her against it because of her family history. Now, with serious bone loss in her spine as well as loss in her hip, but a low NTX score indicating slow progression, she faced a real dilemma.

As more evidence has come in about estrogen and breast cancer, the possible link seems ever shakier, and general medical opinion has shifted to include HRT even for women with a family history of breast cancer. So now that she faced an immediate problem with her bones, Ivy was willing to try it, and I recommended a standard dose of Premarin, with a plan to have a mammogram every six months for three years, then annually after that. But the side effects—everything from weight gain and breast sensitivity to mood swings and depression—soon made her stop. She then asked me to try her on Evista, which set her mind at ease about the breast cancer risk, but she felt anxious and shaky, and started experiencing allergic-type responses (rashes and blotching) to things that had never bothered her before, so she stopped that, too.

Ivy is very detail oriented, and a perfectionist to boot, so she wasn’t about to give up on finding a bone density treatment that would work for her. She knew her bones were fragile enough that she needed some intervention along with good diet and exercise. So I prescribed Fosamax, but she got terrible reflux from it. She started taking an additional medication to reduce acid, thereby cutting down on the reflux symptoms, but was then worried she wouldn’t have enough stomach acid to absorb the calcium supplements and all the nutrients in her food.

So although reflux no longer bothered her, and she had reason to believe the Fosamax was working for her bones, Ivy still wasn’t satisfied with that approach—or with doing nothing beyond lifestyle changes. A second bone scan just six months after the first showed no change, which wasn’t a surprise given the short amount of time and the switching of medications. It was a reality check, however, and motivated Ivy to try Premarin again. This time, 1 started her with a lower dose, .3 mg daily, less than half of what she had before, and it didn’t give her the side effects she had with the standard dose.

At the same time, I recommended she start taking selenium supplements to help reduce her cancer risk, along with the calcium and multivitamin she takes. She continued getting frequent mammograms. She has a sonogram of her breasts as part of her regular checkups, and does a monthly breast self-exam at home.

Ivy loves good food, but is mindful about what she eats, and is now careful to include some good nondairy sources of calcium in her diet every day. Her home is full of beautiful things, and she treats herself well, in general, but lives with a very high level of stress and currently has a lot of emotional turmoil in her life. She walks miles every day, and has for years, but is experimenting with adding a meditative element to the workout in an attempt to reduce her stress. I added trace minerals to the supplements she takes when she went off estrogen the first time, and now she’s also selected some additional nutritional supplements recommended for coping with stress. She also eats flaxseeds for the healthful omega-3 oils and bone-boosting phytoestrogens they contain.

She recently started taking the phytoestrogen ipriflavone. With its proven bone benefits, it should back up the synthetic estrogen, in case the lower dose doesn’t offer as complete protection. But ipriflavone has none of estrogen’s side effects, and Ivy didn’t get mood swings or sore breasts or an upset stomach with this combination.

With a solution finally in place, Ivy turned down my suggestion that she try estriol, a natural estrogen that generally has fewer side effects than Premarin, including no elevated risk of breast cancer. (In fact, some breast cancer patients even use it.) Unless her next bone scan reveals her strategy isn’t working as well as expected, Ivy is comfortable with the precautions she’s taken against breast cancer and satisfied with what she’s done for her bones, and doesn’t want to change anything.

This successful combination of the traditional (Premarin) and the nontraditional (ipriflavone) is what complementary medicine is all about. Neither avenue alone would have gotten Ivy the care she needed. The moral of the story is, with all the choices now out there for preventing and treating low bone density, if you look long enough, you’ll find an approach that works and is right for you.

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“I work mostly with children and teens, so I’m more likely to talk about them, but I counsel adults as well. Every person is an individual. Some are more mature than others. Sure, teens have their own hang-ups and you need to help them achieve independence and get over the hump from child to adult. While there are many similarities in counseling adults, it is sometimes more difficult, especially if they’ve had seizures since childhood. Too frequently, adequate counseling and education were not available to them. They’ve spent so many years with a poor self-image; reconstructing is more difficult than building it right in the first place. They need to learn how to take control of their epilepsy and also of their lives. That’s one of the reasons why I feel so strongly that children need to take ownership of their seizures at the earliest possible point.”

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