Ask A Doc




New guidelines are out and they recommend a healthy (Mediterranean) diet for all patients, new blood thinners if you have a certain heartbeat problem (atrial fibrillation), smoking cessation (duh!), home blood pressure monitoring if you have hypertension, and for ladies with migraines (this increases stroke risk) using a birth control pill without estrogen (which can increase the risk of stroke).

Guidelines are from committees of experts in an official group. Insurance companies pay attention to them, so you may soon be seeing insurances paying for home blood pressure kits like they do for home sugar-checking kits for diabetics.



The federal and state prisoner count as of the end of last year was 1,574,700. This is an increase of 4,300 prisoners from December, 2012.  This does not include a larger number of those in County or City jails, nor those on probation or parole.

There are about a half million prisoners with Hepatitis C in the US. Most will be released and many use needles in or out of prison.  This study showed that it is very convenient to treat them in the prison, since they will not miss their appointments and that the expense is worth it.  With this strategy the transmission of Hepatitis C to many others will be avoided.



As the new ones come out, the insurance plans are thinking of changing to the least expensive but still very effective ones. Harvoni® is a combination pill of two medications, once a day with very few side effects. It is about to be available, having received recent FDA approval. There are others on the near horizon.



A Physician’s Assistant can diagnose, treat, and prescribe medicine under a physician’s supervision.  A Nurse Practitioner (NP) can do the same but needs less supervision. All providers of healthcare must know when to seek help and these two are usually under a physician’s supervision.  These mid-level providers have greatly increased the availability of healthcare in the country.  I have trained and supervised many mid-level practitioners, with them teaching me also since we all learn together.  I have also consulted Neurosurgical and Cardiovascular surgical NPs on my patients and have found them to be excellent. NPs first become a nurse, and then take clinical courses, usually to a Master’s degree level. A PA with a Bachelor’s degree takes courses for 1 year and then clinical training for 1year. Their salaries are less than a physician.  Typically the staff and patients refer to them by their first name, e.g. “Dr Alex” or “Dr. Maria.  All know that they are not physicians (M.D.s or D.O.s). There isn’t a problem with respect or authority since the staff and patients are aware of their important role.

Research has shown them to be quite competent and efficient. They typically spend more time with the patients, educating them on their issues. With more money for (and highlighting the importance of) primary care, there are many more mid-levels being trained and hired.



Providers must read, study, and listen to experts to keep up-to-date. Many guideline electronic applications are available to help the provider diagnose and treat patients.  Blood and imaging tests as well as consultant reports are very helpful.  (There are restrictions on what we can order due to high priced tests and medicines sometimes.)  Listening to the patient and asking precise questions also add greatly to the large database a provider uses to help you. Of course examining a patient adds to the database, even if nothing abnormal is found.

Patients seem to trust hard data like a scan or lab value as true or false. Providers know that sometimes the test results can be misleading.

There isn’t yet a computer that can weigh each piece of the evidence to put the case together to make the best guess of the diagnosis and treatment. This is a complex thought process that has its beginnings in training and continues daily after that.

An example is a test that matches perfectly with the other tests and the story the patient gives.  Another example is a rash my patient had recently that could be from one of 6 medications, or syphilis, or HIV being knocked down and the immune system rising quickly, or something else. Each of these possibilities has a score in the provider’s mind and the score is adjusted by the information the provider looks for.

We are pleased that patients are aware of this complex process and respect the providers’ opinions. The practice of medicine is challenging, and even fun for many of us providers–we enjoy puzzles and being a detective.



There are 5 organizations that issued guidelines this year: the US Department of Health and Human Services (DHHS), the International Antiviral Society–USA, the British HIV Association (BHIVA), the European AIDS Clinical Society (EACS), and the World Health Organization (WHO). THey have much in agreement but there are areas of disagreement.


Here is the breakdown of when these groups recommend starting therapy:

2 American GroupsE Any CD4
2 British and European Groups start if <350, consider if <500
World Health Organization start if <350


There is agreement not to start if the patient isn’t ready, e.g. considering chaos in their life, mental illness, substance abuse, immaturity.  I don’t start if the CD4 is high and the viral load is low since these are long-term non-progressors or elite controllers who are able to control the virus well without medications due to an uncommon mutation.

Of course there is agreement to start no matter what if they refuse to wear a condom, have chronic Hepatitis B (2 drugs treat both conditions), kidney failure, pregnancy, tuberculosis, etc.

Keep those questions coming. Be Safe!


Daniel Pearce, D.O., FACOI, AAHIVS
Clinical Associate Professor of Medicine, Loma Linda University School of Medicine
Adjunct Professor of Internal Medicine and HIV, Touro University California College of Osteopathic Medicine and Midwestern University Arizona College of Osteopathic Medicine
Researcher, Veterans Administration Hospital, Loma Linda
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside



Note: please understand that some of this information was written 1-2 months before you read it.