MarkAlain Déry, DO, MPH, FACOI

Monica Gandhi, MD, MPH

Sneha Jacob, MD

Hamadullah Shaik, MD

Urban Health Today

A roundtable discussion, moderated by MarkAlain Déry, DO, MPH, FACOI, focused on disparities in the prevention, diagnosis, and care of HIV. Dr. Déry was joined by Monica Gandhi, MD, MPH, an infectious disease doctor, professor of medicine, and associate chief in the Division of HIV, Infectious Diseases, and Global Medicine at the UCSF School of Medicine; Hamadullah Shaik, MD, an assistant professor in infectious diseases at Rutgers University, Robert Wood Johnson Medical School and associate chair for Infection Prevention at Robert Wood Johnson; and Sneha Jacob, MD, an associate professor of medicine at Rutgers University, Robert Wood Johnson Medical School and an HIV specialist with a background in internal medicine.
In the second segment of this roundtable series, the panelists discuss structural barriers to HIV prevention for marginalized communities, such as health care policy, education, and insurance coverage, as well as ways to address or eliminate those barriers and improve access to HIV prevention.
Find more of this roundtable discussion <a href="https://urbanhealthtoday.com/page/hiv-roundtable">here</a>.
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Dr. Déry: How can health care systems and policies be improved so that they can better support and promote HIV prevention efforts such that our patients don’t have to get off of their health care just so they can access some of these Ryan White [HIV/AIDS Program] services that are really geared for people living with HIV?
Dr. Jacob: I think having better dissemination of information, probably also within the provider community, is important. Sometimes we are preaching to the choir when we’re talking among HIV and infectious disease (ID) providers. If you look at the sites we represent, we are groups of people who know quite a bit about pre-exposure prophylaxis (PrEP) and prevention.
Here in Central Jersey, we did a large-scale survey of the South Asian community, who we have a large population of, partly because we were seeing South Asian patients with HIV, but also to look at the physician community to see how often they are prescribing PrEP and also how often they’re screening for HIV. We did find less knowledge or less common screening and PrEP prescribing, particularly among physicians who’d been in care longer or been in practice longer.
Even when I get a newly diagnosed patient with HIV who’s been in primary care prior, my first question—especially if it’s a young gay man—is, &#8220;Have you ever been offered PrEP?&#8221; And there are many patients who may have heard of it but had never had that discussion with their physician and would really need to go and actively seek it. I think the provider community being more aware can also impact policy and advocacy on a policy level and on a health insurance level. I think that’s critical.
Dr. Déry: Thank you so much. Really very insightful. Yes, awareness is so important, especially when it comes to provider awareness. I get the sense that some of my colleagues, at least here in New Orleans, think we’re better off with respect to PrEP awareness and HIV awareness. I feel like I’ve been ringing this bell for 10, 15 years, but it seems like that ringing is finally getting into people’s ears, fortunately.
Dr. Gandhi: Can I interrupt and say one thing based on what [Dr. Jacob] just said? Because I think it’s really interesting. The one thing I keep comparing this to is contraception. When only OB-GYNs gave out contraception, it was pretty limited. Then when the primary care provider, the emergency room provider, the urgent care provider started acting like that was within their purview—which it is because it’s preventative health—then we had better uptake.
It feels like with PrEP that it can’t [just] be ID physicians. It can’t just be HIV doctors. It has to be taken on by primary care physicians, where they see it as part of preventative health. I think there’s been this concern that you have to do monitoring with TDF/FTC (tenofovir disoproxil fumarate and emtricitabine), renal, and so forth, but it’s not very onerous. And with intramuscular cabotegravir, there’s hardly anything in terms of monitoring. You just need to do HIV testing. I would really encourage that constant discussion of the primary care provider having [to] really take this on.
Dr. Déry: Along those lines—and it’s something that you mentioned when we first started the discussion—can you talk about how socioeconomic disparities, such as poverty and lack of access to health care, can affect an individual’s ability to obtain some of these HIV preventative measures that we’ve been talking about? How do you and either your health care system or your clinic address those issues?
Dr. Gandhi: It’s really interesting to think about what the adherence barriers actually are across the planet. I’ve done work in India, and speaking to Dr. Jacob and the South Asian community, stigma is a huge barrier to uptake of HIV medications. They actually don’t even encourage HIV prevention yet. But every place is different, country population stigma is a big one internationally. Stigma is definitely still here, of course, in the United States, especially among men who have sex with men, mainly who are from racial and ethnic minorities who may not want to disclose their particular sexual orientation. Stigma is still there, absolutely.
What we’ve seen in the urban centers here, more in the United States, is overlap of substance use, which worsened during the pandemic and is still very much with us. Overdose deaths are the number 1 cause of death among those 45 years and younger in the United States. Here in San Francisco, overdose has surpassed any other cause of death for people living with HIV. Substance use is a very big barrier to taking a pill every day. Then, depending on your urban center&#8230;. We have a very big problem with homelessness and not having housing security. Mental health concerns also rose during the pandemic.
All of these together, I think, are the barriers in urban centers, but stigma is still pervasive. Sometimes it’s forgetting [medication], sometimes stockouts, sometimes transportation, childcare, or you don’t want to have people see your meds. There are lots of barriers to adherence. These are the structural determinants. These are the structural issues in getting on prevention and treatment.
We can’t provide housing for everyone. We wish we could from our clinic. We advocate for housing, certainly, but what we do is we have a program called Pop-up. Our Pop-up program at Ward 86 is exclusively for those who are homeless and who don’t have virologic suppression. The entire premise of the Pop-up program is low-barrier access. You can come in anytime. No appointments are necessary because that can be really hard when you’re living in a tent. You come in, and the same team forms around you, so there’s that continuity of the same social worker, nurse, the same small group of providers.
We will do whatever you want in terms of what you’re coming into the clinic for, in terms of an urgent care problem, but we will also do primary care provision, vaccines, and try to get people on antiretroviral therapies (ART). We do provide economic conditional incentives for getting on antiretrovirals and getting to virologic suppression. We combine substance use treatment with that, and we’re especially excited if people are willing to do the long-acting [treatment] because we are using long-acting ART a lot in our homeless population. We’ll try to pair those interventions with substance use treatment. So, lots of incentives for that as well, like clean urines, or at least cutting down on drugs. That’s one way we’ve tried to address those living with homelessness, which is overlapping with substance use.
Regarding substance use, we are trying to raise awareness that we do have treatments—not the most amazing treatments for methamphetamine, which is actually more of our drug of use here in San Francisco compared with some areas in the East Coast—but we’re still trying to get everyone on substance use treatment who’s willing.
Finally, in terms of mental health, we’ve actually been really interested in the long-acting antipsychotics, and, again, paired with long-acting ART. The biggest strategy we’ve been using is kind of bold, because it’s not approved, but we’re using long-acting ART in those who are viremic, in those with adherence challenges, and in those who are homeless. That has been the biggest game changer that we’ve seen over the last 2 years. Luckily, because we have Medicaid and we can get long-acting cabotegravir and rilpivirine, it’s been really, really quite successful.
Dr. Déry: That’s amazing. Thank you for that. One of the key things that I heard there was something that I’ve done in my clinic as well. You’ve removed obstacles for getting somebody to see a case manager or a provider. I think we’ve all identified what those obstacles were&#8230; And I didn’t even realize they were there. They were just part of the structure of medicine. But it wasn’t until we started doing same-day start or rapid start that I realized, “Oh, these obstacles&#8230; I just need to be available or I need to have somebody available.&#8221;
I’m the only ID person in a large 50-clinic Medicaid-providing system throughout the state of Louisiana. When there’s a positive HIV [diagnosis], I get a text. And within 2 or 3 minutes, no matter where I am, I’m doing a virtual visit with somebody in one of those clinics. Just from even our perspective, it took a while to get people to understand the importance of separating yourself from the way medicine used to run such that we remove obstacles. One hundred percent. And that’s what I heard there. I think that’s amazing work.

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Panel Discusses How to Address Structural Barriers to HIV Prevention

Panelists discuss how health care policy, education, and insurance coverage impact access to HIV prevention, and ways to address or eliminate these barriers.