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March 18, 1998

Controversies: The Role of HIV Specialists

Author Affiliations

Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor

JAMA. 1998;279(11):833-835. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-11-jac80001

To the Editor.—While I wholeheartedly agree with the comments of Drs Zuger and Sharp1 regarding the need for HIV specialists, their arguments for super-specialized care also apply to other infectious diseases. As a physician who consults on all cases of multidrug-resistant tuberculosis in Los Angeles County, California, I am deeply troubled by the trend toward elimination of categorical tuberculosis (TB) clinics based on the belief that any primary care physician can treat this disease. While it is true that many generalists can and do deliver excellent care to their patients with TB, others may not be able to do so for various reasons, including a low incidence of TB in their geographic area. Tuberculosis care, more often than not, is complicated by socioeconomic conditions, psychiatric disorders, and other circumstances that lead to poor adherence to therapy and poor treatment outcome. I suspect that most primary care practices have neither the time nor infrastructure necessary to attend to the public health issues related to TB, such as finding and screening contacts and delivery of directly observed therapy. Finally, the treatment of multidrug-resistant TB requires the skill and expertise that only experience and hands-on training under knowledgeable mentorship can provide. For these reasons, I believe there is and will continue to be a need for super specialists, especially as medical knowledge and technology continue to race ahead at breakneck speed.