Challenges and Opportunities for Patients With HIV During COVID-19 - Episode 3
Health care disparities seen in patients with or at risk for acquiring HIV and considerations for supporting patients, especially during the COVID-19 pandemic.
Moti Ramgopal, MD, FACP, FIDSA: I work with the poor population, patients without food and without good nutrition. Today’s challenges are elderly patients who are having difficulty getting to the office, or who have difficulty with cell phones and apps on their phone. The disparities were are going to tend to see down the road are based on elderly care as well. How do we address those? We’ll have to pick those patients up because transportation remains a problem for the patients over the age of 50.
The younger patients, they still need someone to have a conversation with. Diabetes, hypertension, weight gain issues are all the challenges we are facing. But the major issue I tend to focus on a lot more is that you're facing challenges of the MSM [men who have sex with men] population. You’re facing challenges with abuse in their home environment that is occurring more and more. How do we fix that in an HIV perspective? It's very difficult. That's why we’re beginning to see the numbers are probably going to start increasing again.
One of the health care disparities is that health care providers themselves are facing a heavy emotional burden, an emotional burden of what's going on in their home. A lot of health care providers have been affected on a firsthand basis by COVID-19 [coronavirus disease 2019]. They've been working in the hospital, they have family members who have been sick and have died from COVID-19.
Oftentimes when we look at the challenges we face in health care with HIV now, it's not just the patient challenges. It's the quality of care given to patients by the health care providers, and that’s because of the huge emotional impact of this disease. COVID-19 has affected all of us. And then we look at patients who feel disenfranchised, patients who feel disengaged. And I particularly mention Haitian patients, which I have many of those. I find sometimes they feel as though they're culturally challenged. They have language barriers, which are still there. Hispanic patients still have those challenges. When you add COVID-19 to that layer, it becomes more difficult.
You look at the lower socioeconomic status of my patients. Most of these patients are bartenders, or they are working in a laundry business, or in restaurants. And now most of those jobs are gone. Or they may be working in the transportation industry, or a food delivery business, and those jobs are gone. Now these patients are just eking out a living. When you're eking out a living, the last thing that comes to your mind is your medications. The first thing that comes to your mind is your food, your children, and the social services that you can provide. And what falls farther and farther behind is buying those medications, and paying the co-pays and getting those meditations.
It's going to be more challenging now because as we are entering into the second wave and then the third wave, this is becoming a more and more complex issue, how we're moving forward with this.
Mary Malek, PharmD, BCPS, AAHIVP: We've seen multiple health care disparities being amplified due to COVID-19 for patients with HIV and for those at risk of HIV. One major health care disparity that I want to speak about is age. Age plays a huge role when it comes to COVID-19, and also for HIV. If you remember in the beginning of COVID-19, we understood that it was more prevalent in the older population, in patients who have multiple comorbidities. But for the younger population, they were a little calmer. Life was just the same as it was. You remember even the governor of New York saying so many times to our younger population, “Be careful, because you might not show signs and symptoms of the disease, but you're a carrier, and you might infect those around you with the disease.”
A huge health care disparity is age because the younger population sometimes doesn't feel that they're at risk. They don't see themselves at risk. They don't see any problem, because they feel young, healthy, strong. They think, “This is not going to affect me like it affects everybody else.” But we've seen the opposite happen in COVID-19. We've seen a lot of younger patients get the infection, unfortunately, and die from the disease. It's not the same as how we understood it in the beginning, and I think it took time for us to understand that.
That relates to HIV, especially HIV prevention, because nowadays we're seeing that a lot of patients who are seroconverting are the younger population, the ones from 20 to 40 years old, around that age. A lot of new HIV infections are happening in that group, less in the older population, greater than 50 or 60 years old. That is an important wake-up call for everyone, and for the younger population to understand that disease is not tied to an age, but behavior is. If you're older and having this behavior or younger and having this behavior, you might acquire the disease.
We should not be ashamed to start a medication for HIV prevention. We should not be ashamed to be on medications. The shame here is knowing that you have a risk and not paying attention to that risk, and not taking action to prevent that risk.
Again, the health care disparity is amplified here, because we see a lot of attention is paid to birth control and pregnancy prevention in younger adults. We are teaching them in high school about it, we're starting early in middle school. We're seeing fewer younger people getting pregnant.
But we're not doing the same for HIV. Not a lot of younger adults know what is HIV prevention. Not a lot of younger adults know what is PrEP [pre-exposure prophylaxis] or how to get access to PrEP. That's very unfortunate and it's something that we need to work with, with our younger population, to understand. Just like you take birth control to prevent pregnancy, just like you take Plan B, we have PEP, post-exposure prophylaxis, to prevent HIV, even if you were exposed to it. Younger people know how to access birth control. They know how to access Plan B. But they don't know how to access PEP and PrEP, and they don't know that they're at risk for COVID-19.
We need to pay more attention to that. We need to make our patients feel like it's OK to be at risk, but you have to take action to prevent disease, and it's OK to be on medication at a younger age.
We, at the health plan, try to do that a lot with our patients, because about 10% of our population is homeless, or people with transgender experience who are HIV negative and might be at risk for HIV. What we're doing is we are doing an HIV risk assessment with these patients. We're calling them. We're going through questions, reasons why somebody might be eligible to be on PrEP, and we're asking them, “Do you participate in any of these behaviors that might put you at risk?” If they answer yes, we try to connect them to a PrEP provider. We try to connect them with health care and give them the education, the knowledge, the awareness of what is HIV, what is HIV prevention, and how you can protect yourself by just taking 1 pill a day from this HIV epidemic we're going through.
I think, again, age was definitely amplified during this time. Younger people need more education, more awareness. A lot of people do know about it. But we need more people to educate and to get the word out about HIV prevention and keeping yourself safe and understanding risk, and keeping engaged with the health care system to prevent risk.