SARS and HIV: Perspectives from the Front Lines
Kevin Frost, Dr. Nicholas Paton, and Dr. Patrick Li in conversation when the TREAT Asia Steering Committee met in Kuala Lumpur in May 2003.
June 2003—Several TREAT Asia sites found themselves caught in the whirlwind of SARS when the epidemic swept across parts of southeast Asia earlier this year. On the front lines were Dr. Nicholas Paton of Tan Tock Seng Hospital in Singapore and Dr. Patrick Li of Hong Kong’s Queen Elizabeth Hospital. When the TREAT Asia Steering Committee convened in Kuala Lumpur, Malaysia, in May, they spoke with amfAR’s Vice President of Clinical Research and Prevention Programs, Kevin Frost, about the impact of SARS on their work with HIV patients, the parallels between the two diseases, and the lessons learned from a public health crisis that no one saw coming.
Frost: How did SARS affect care for HIV patients in the context of your clinics?
Paton: The old-fashioned quarantine-isolation hospital in Singapore—the Communicable Disease Center next to Tan Tock Seng Hospital—functions as the HIV hospital. So with this outbreak, the main facilities in Singapore used to manage SARS also happened to be the main facilities used to manage HIV in normal times. The staff managing the HIV patients were then also given the main responsibility for managing the SARS patients. So there was a direct impact on the physicians’ time and also on the facilities being used to manage the HIV patients.
Frost: Were you quarantined if you were seeing SARS patients?
Paton: No, we weren’t quarantined, but we had to take precautions—using N-95 masks, changing gowns and gloves between patients. We tried to split the doctors looking after SARS patients and suspected SARS patients from the doctors looking after HIV or other patients. But from a manpower point of view, that wasn't possible to do entirely. Inevitably the doctors were required to manage groups of patients, both HIV and SARS. We were taking temperatures three times a day, and if you had a fever, be it from an upper respiratory tract infection or anything else, you were quarantined at home. If it looked like you had symptoms of SARS, you were put into the hospital.
Li: In Hong Kong we had a great number of patients. At one stage, we thought about concentrating all of the patients in one hospital. Very soon we found that a lot of them required ICU support and that overwhelmed the system. So most of the time we spread patients among the different acute hospitals. Each of the hospitals had isolation areas for SARS patients and intermediate wards for suspected or probable patients. In the other areas we reinforced infection control measures. In Hong Kong in general, we have very few infectious disease specialists, so the care was really given by the respiratory physicians, supported by the general internists.
I think there are two elements that affected patient services. First, because of the decrease in manpower, we had to try and reconfigure the AIDS service so it would result in minimum inconvenience and disruption of care.
Second, patients were quite concerned about going to the hospital because of the possibility of acquiring an infection through contact with hospital staff and other patients. We advised all patients coming to outpatient clinics to wear masks. This was especially the case for all HIV-infected persons because we knew they were immune-compromised.
Paton: For the first few weeks, we actually contacted the patients and said, “Look, don’t come to the clinic unless you are sick. If you need a prescription for your repeat medicines, we can send it to you or just come to the pharmacy at the back of the hospital and we’ll write it for you and you can pick it up.” Over time some of the HIV patients would get sick, so we’re now seeing a rebound and our in-patient beds are full of patients with opportunistic infections again. After two weeks we realized that we couldn’t actively keep people away any longer.
Frost: Have you seen anyone with both HIV and SARS?
Paton: No, but we have seen patients presenting with apparent symptoms of SARS who actually had HIV. They had pneumocystis pneumonia (PCP) or some other opportunistic infection. So, paradoxically, the SARS outbreak has actually been quite good for identification of HIV patients. With people getting their temperatures checked all over the place, GPs are referring patients with a fever and any suggestion of pneumonia or some other pathology to the one hospital that has infectious disease expertise in HIV: Tan Tock Seng.
Li: In Hong Kong we identified at least two patients who presented with acute pneumonia. Under normal circumstances we would have thought of PCP, but with the SARS outbreak, everyone with fever or pneumonia was a suspected SARS case. Ultimately other features were discovered that suggested an HIV infection, and they were found to have PCP. The interesting thing is that even though they were admitted to wards for suspected SARS patients and might have been exposed to infected individuals, none of them actually got the infection.
Frost: Some reports have suggested that people with HIV may somehow be less susceptible to SARS or show less symptomology. Is this possible, do you think?
Paton: Certainly you would expect them to show less symptomology. A number of the more difficult patients with SARS, particularly those who were elderly or had renal failure, and whose immune systems were not functioning particularly well—they generally didn’t show much in the way of symptoms, apart from some low-grade fever. We don’t know the pathogenic mechanism but you would expect that, since HIV patients are immune-compromised, they might also fail to show symptoms.
Frost: We keep hearing the concern that resources spent on SARS are resources taken away from HIV. Do you think that’s true?
Paton: No, I think it’s basically a separate budget. In some ways, HIV patients have probably benefited in Singapore because there have been extra resources put in to develop facilities at the Communicable Disease Center to respond to SARS. Now that SARS is disappearing, there may be some residual benefits at least in terms of more hospital beds of higher standards.
Li: In Hong Kong, I don’t think that there’s any real impact in terms of resources. But many practices and procedures have changed for doctors, especially in terms of infection control.
I see a lot of similarities between the SARS outbreak and the HIV epidemic in the early eighties. At that time, too, people were not very sure of what the underlying agent was and they didn’t have a diagnostic test. They didn’t have treatments and certainly no antiretrovirals. And then there was isolation, discrimination, fear, stigmatization, and we’re seeing that again with the SARS outbreak.
Also, we are seeing health care workers directly affected. They are seeing what it’s like to be discriminated against, to be quarantined and be put under travel restrictions. I think, in a way, the public has also realized what it’s like to be considered infectious by other people and other countries. I hope this has changed perceptions in Hong Kong so that people have become more health-conscious, more tolerant, and more sympathetic.
A lot of our patients have said to me that HIV’s not so scary compared to SARS. I think they’ve realized in a way that even though they have an infection which is not curable yet, at least we know how to treat it and how it is prevented, and we can prevent transmission to other people. For SARS, we’re still learning about it. I think this gives the patients some perspective on their HIV status.
Paton: One of the most interesting things to come out of this is the discrimination and stigmatization issue surrounding the SARS outbreak. Patients who have been infected have been identified, sometimes by name in the newspapers, they have been stigmatized and have received hostile phone calls from members of the public. Also, colleagues in my department have had their kids singled out at school for special temperature taking and other precautions. Nurses have had apartment leases terminated. And taxi drivers have refused to pick people up from the hospital or drop them off there.
The government realized early on that something needed to be done about discrimination and stigmatization if the country was going to respond appropriately to the outbreak. So they set up ministerial hotlines for anyone who faced discrimination so that the ministry could take action immediately and send out a team of educators to the workplace or whatever. All of these issues have been brought into the public domain, and all of them apply exactly to HIV infection.
Frost: But are they being applied to HIV? Is HIV getting worked into those public discussions?
Paton: Not actively, but I think it’s too early. This SARS outbreak is just coming under control, but I suspect that it is not too difficult for people to make that connection in their minds. Maybe a few months down the line when SARS is done, we’ll see whether there’s been any softening of public attitudes towards HIV. But I think the kind of discussion that has been opened up can only be good. I think it’s good within the hospitals as well. SARS is seen as a much greater danger to health care workers than HIV, so now people are having to face up to the fact that they have to take care of patients. It doesn’t matter what the personal danger is; they just have to get on with the job. I think that may help to put HIV care into perspective.
Frost: The cause of SARS—the corona virus—was identified within weeks, the genome was mapped in a matter of days, and treatments are already being studied. A lot of the credit for the speed of the response is due to international cooperation and a commitment to that at the highest levels. Do you think there are lessons there for a network like TREAT Asia as it relates to regional collaboration on HIV?
Li: I think we are seeing a lot of parallels between the response to HIV and the response to the SARS outbreak. But in the area of scientific research, I think there could be more collaboration. And I think we are lacking in the area of frontline clinicians communicating with each other, sharing experience in terms of treatment and precautionary measures. The TREAT Asia model would be a good one because with a network system, you can seek help from others facing similar problems and also think about collaboration in terms of research and other projects.
Paton: I think that the two diseases are completely different in academic terms. SARS just came completely out of nowhere. It overwhelmed the medical system and we had no idea which way it was going to go. Whereas with HIV, we know how it is transmitted, how it is going to evolve, and so on. With SARS, there was an extreme pressure to learn from everybody who was affected because this might have become an insurmountable health issue. With TREAT Asia, we’re dealing much more with building networks for training, planning, and research, a much more long-term thing. So I don’t think the parallels are that strong, apart from the fact that communication of experience is generally better than everybody managing things in their own countries.
Frost: If you were looking into a crystal ball a year from now, is SARS still a big story or not?
Paton: Even if the numbers are not a big story, I think it has changed the way hospital medicine is practiced. I don’t think people are going to neglect infection control again in the way that it has been neglected in health care institutions almost worldwide. It’s not been given the attention it deserves. It’s going to change the way people practice in terms of workflow, triaging in clinics, probably the design of hospitals in the future, numbers of isolation beds, the way patients are managed in isolation.
Li: I think we probably will be seeing SARS for some time. I don’t think there’s any infection that’s been totally eradicated so easily. Hopefully in a year’s time, we should have better diagnostic facilities and tests, and also maybe more understanding about the pathogenesis and treatment, and better public awareness of the importance of hygiene and personal environment. I think that would probably contribute to limiting future outbreaks. I think the SARS outbreak exposed many weaknesses in our health care systems.
Frost: Thank you both.