Barriers to Obtaining Optimal HIV Treatment


Dr Adam C. Welch drives a discussion highlighting disparities in health care equity affecting patients who receive an HIV diagnosis.

Adam C. Welch, PharmD: I want to expand a little bit on what you all mentioned, which is the social determinants of health. When a person is diagnosed with HIV, you’re taking care of the entire person. There are other things in their life that they have to manage now, including the pill burden and potentially 50 years of medication therapy. Talk a little bit more about what someone would experience with a diagnosis of HIV. What are some of the other social determinants or inequities that we’ll see in society?

Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: Absolutely. Basically, social determinants of health are anything that the patient needs to be intact and functioning and in place for them to successfully remain engaged in the health care system taking medications compliantly. So they have to have some kind of medical coverage. I’ve had tons of people during the pandemic become unemployed, fall off of employer-based insurance, previously never utilized Medicaid or Ryan White Services, and don’t know that they exist. So patients just fall out of care for a few years and come back with advanced AIDS because they didn’t realize that they had access and how to access it. Plenty of people who are newly diagnosed, if they don’t have insurance, they don’t know about Ryan White. You don’t see any commercials on TV advertising Ryan White, but we have covered people with HIV. So access to insurance is a big one. Financial. I have so many people who just can’t get to a clinic. Thank God for telehealth. It’s helped, but I eventually have to lay my hands on them. And if they don’t have a car or they can’t afford to keep it repaired, or they can’t afford the gas money or the insurance, or if they don’t have money for buses or the taxi service doesn’t come, which is common in our state, then people miss appointments. So that’s another one. Another one is the whole behavioral health and substance use issue. People who are living burdened and in pain with stressors, their medical care is down here. Where they’re going to eat and where they’re going to sleep is up here. If all of their more basic needs aren’t met, they’re not even going to make it to us. I have so many people who are struggling with unmet behavioral health needs, and there are just not the resources to care for them, let alone in the West, we have a huge methamphetamine epidemic and there’s no treatment. I’ve got people who are constantly falling out of care with that. And of course, I’ve got a large cohort of patients who are bipolar, methamphetamine [addicted], and homeless. So sure, I’m mandated to address their social determinants of health. I can diagnose it, but I have nothing to refer them to. So part of what we’re going to talk about at the end is, what do we need to do to address this? We need a lot more support to meet these social determinants of health needs.

Alina Orozco, RN: I think that’s where the payers also have to come in and educate and support the providers to know that there are benefits maybe that they’re not aware of, that maybe the payer is providing and they’re just not aware of it. I know in Florida we have benefits around food insecurity. We have benefits around housing assistance, and a lot of times providers and folks just don’t know about it. We have to do a better job of educating those individuals who are touching the members, or the clients or the patients and letting them know, here’s a resource for you, let’s work together to address the needs holistically. The other thing that we’re very concerned about, I think everyone, at least definitely from a payer perspective and ours, is the redetermination of Medicaid eligibility with the unwinding of the public health emergency. Very concerned. It started last month, and we’ve been doing tremendous outreach and we continue to do that. [We are] very concerned that people are not going to have coverage and are going to show up to their local pharmacy to pick up their HIV meds and realize they’re not covered. We’ve been trying to proactively work with our community-based Ryan White organizations to make sure that people are referred to where they can get help so that there aren’t any gaps in care.

Adam C. Welch, PharmD: So it sounds like the clinicians who are touching the patients every day and the payers who are financially supporting this care have the same goals in mind. We just need to do an effective job communicating those goals and those services and what we can bring to the table so that we can best take care of our patients. I want to talk a little bit now about some of the barriers to screening and testing for HIV. Christian, talk to me a little bit about some of the barriers that you’re seeing with screening.

Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: First of all, we have really good tests. We have rapid tests that are fairly sensitive and specific, and we have good recommendations from the CDC [Centers for Disease Control and Prevention], which really tells us that all adults should be screened for HIV at least once in their lifetime. And if you have additional risk factors, probably annually is how most people interpret that. But we haven’t implemented that fully. And this is another place where I think the payers can help because they have all the data on who’s been tested and who hasn’t been tested. HIV testing needs to be ubiquitous. It needs to be free and needs to be everywhere, especially for some of the patients who are not fully engaged with the health care system. Maybe they’ll just go to bars or clubs or bathhouse places that really need to have testing available for them to reach those people. What about homeless people that don’t make it into the clinic very often? Those places, in sort of nontraditional settings, I think we really need to allow testing there. I think we’ve learned a little bit from studies that implement opt-out testing, for example, in emergency departments [EDs]. So lots of people come in through the [ED]. Many people come to the [ED] for their primary care, to be honest. And programs that have implemented opt-out HIV testing for every single person that walks through the door and they find a lot of undiagnosed people. They can link them into care. Interestingly, the people that tend to opt out and say, “No. I don’t want that. I’m not at risk,” actually have a higher HIV incidence than other people. So an interesting thing about the human condition and denial about risk, but just making HIV testing really everywhere available, accessible for everyone. In San Diego, we’ve done a little bit of this by going to nontraditional settings and doing rapid testing at bars and clubs and then having really good services right there, right available to get people linked into care right away.

Ann Khalsa, MD, MSEd, FAAFP, AAHIVS: We’ve also implemented, opt-out testing across our county hospital network of FQHCs [Federally Qualified Health Centers]. So we’ve been doing opt-out testing in the [ED]. And what people need to realize is opting out isn’t saying, “Hey Christian, would you like an HIV test today?” Because now he has to say yes, which means he also has to somewhere acknowledge a risk factor or at least acceptance of risk. Whereas instead, we say with an opt-out, “Hey, we do HIV testing on everyone, so we’re going to do it unless you say no.” You reflip it so they don’t have to acknowledge their risk. But we have implemented that across all of our FQHCs because a lot of people, like you said, they’re not coming in with routine chronic problems and so they may not be getting an HIV test. Our only time to see them maybe when they come in with pink eye or whatever their acute illness or symptom is. And we need to routinely ask them, “We do HIV testing for everyone, is that OK if we just include that for you?” So we need primary care doctors, urgent care, and [EDs] to be offering more testing because a lot of people don’t realize their condomless sex ever might have put them at risk, and in fact, it may have.

Christian B. Ramers, MD, MPH, FIDSA, AAHIVS: One additional point I’d like to make is the testing program shouldn’t just be focused on the positives because that opportunity to get a negative test is an opportunity to link someone to prevention services as well. So it’s called a status neutral approach. If somebody’s at risk and positive, they go right into care. We try to start them on therapy as soon as possible to render them noninfectious, and to get them linked to care for their own health. But if they’re at risk and negative, we can link them to PrEP, pre-exposure prophylaxis, to prevent that person from getting HIV. I’m sure we’ll talk about that later.

Transcript edited for clarity.

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