Jonathan Colasanti, MD, on Delivering HIV Care in 2021

In this podcast, Jonathan Colasanti, MD, talks about caring for patients with HIV in 2021, including why some current care models are succeeding, why some are failing, and how to improve health outcomes for patients with HIV.

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Jonathan Colasanti, MD, is the medical director of the Infectious Disease Program at the Grady Health System in Atlanta, Georgia; an associate professor of medicine in the Division of Infectious Disease; and an associate professor in the Department of Global Health at the School of Public Health at Emory University in Atlanta, Georgia. 



TRANSCRIPTION:

Jessica Bard: Hello everyone, and welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator Jessica Bard, with Consultant360 Specialty Network.

According to the most recent data available from the CDC, an estimated 1.2 million people in the United States had HIV at the end of 2018, of those people about one in seven did not know they had HIV.

Dr Jonathan Colasanti is here to speak with us about where our current care models are failing and what we might need to do to improve health outcomes for patients with HIV. Dr Colasanti is the Medical Director of the Infectious Disease Program at the Grady Health System in Atlanta, Georgia.

He's also an Associate Professor of Medicine and Infectious Disease and at the School of Public Health in the Department of Global Health at Emory University in Atlanta, Georgia.

Thank you for joining us today, Dr Colasanti. You're presenting your session, "HIV Care Delivery in 2021," at ACTHIV 2021. Can you please give us an overview of your session?

Dr Jonathan Colasanti: Sure. With this session, really, my objective is to make us think a bit outside the box. Push the envelope on where we're willing to go as a system, with our care delivery. I'll talk a little bit about differentiated care and how that contrasts a bit with different models of care and giving patients options.

What you'll find is that throughout it, many of the models of care, what's inherent to them is integration, multidisciplinary, warmth and compassion, and cultural humility, and leading with that. I talk a little bit about how COVID has affected care delivery, and where it may get us in the future, especially with regard to Telehealth as we learned a lot about that this year.

There are also some specific sessions around COVID and HIV at the ACTHIV Conference. I took this as an opportunity to try to dive into where our current care models are failing. What we might need to do to take care of what's often referred to in the field of HIV as the last 10 percent. That comes from the UNAIDS targets of 90‑90‑90 or 95‑95‑95.

In other words, about 10 percent of the population globally, even with the targets there, may not be perfectly cared for and how do we care for that population? In the United States actually, when we think about our HIV care continuum which I do go into a little bit, our gaps are slightly different than where they are globally.

That end number, in terms of total number of individuals in our country that are living with HIV that are in care and biologically suppressed, hovers around the 50 percent mark.

We have a long way to go. I tried to explore where we might improve those outcomes.

Jessica: Let's explore that. Can you dive a little bit deeper? Where are we today on HIV care?

Dr Colasanti: Sure. It's funny, we have a great model for HIV care in this country with the Ryan White HIV AIDS program, which has been around for decades, as a payer of last resort for persons with HIV. Yet, despite the fact that this is for a payer of last resort, they've taken the model of a comprehensive medical home as what they try to do in the Ryan White program.

That's what so many of the Ryan White programs do so well. Their numbers for patients that are engaged in care are great for viral suppression, like 88 percent. You have to pause and say, "Well, why do we actually need to reevaluate this model?"

Again, it comes down to that small group of individuals that even with all that, with all the Ryan White program currently offers, we're still failing them. Our system is still failing the patient.

When you look at disparities and outcomes with HIV and look at deaths, first and foremost, there's a tremendous disparity between people of color, in particular, African American and Black populations, compared to other populations with upwards of eight times as greater risk of death, no matter what region of the country, but that's especially magnified in the US Southern context.

Jessica: That's going right into my next question. You mentioned touching on where current care models are failing. Where are the gaps and disparities that exist today in HIV care?

Dr Colasanti: The models that are...Again, the disparities, you see them across all of our spectrum of HIV care continuum, from diagnosis to linkage, to care, to retention and viral suppression. Ultimately, that death number is what bothers me the most, because that proves how profoundly we do fail our patients at times.

Again, you can look at any stage of the care continuum where we can see gaps, and you can see disparities, whether that be among people of color, or our youth or transgender populations, oftentimes, or folks that have mental illness or substance‑use comorbidities, or gaps in social services, such as housing and food.

All those individuals tend to do worse along the care continuum. We have to find models of care that address each of those. That can often do it, whether it's simultaneously or nimble enough to go between different models of care, and get patients to the model of care that's going to fit with them as their dynamic life also changes.

Jessica: How do we get HIV care to people who need it, despite our limited resources?

Dr Colasanti: First and foremost, we have to build our workforce. We have limited resources in terms of dollars but we also have limited resources in terms of the workforce to care for this population, which is magnified in the southern context, which I talked about a little bit more in detail in the talk. We have to improve that.

There's a new bill in Congress that late Senator John Lewis had actually put forth before his passing, I believe it's called "The Heel Act," which would pay for student loans for a lot of the different professions that would care for people living with HIV, if they practice in an under‑resourced setting.

That hopefully will encourage a stronger workforce, but then working with the current resources we have, I think we have to use those resources a little bit more smartly and a little bit more efficiently.

That's where you look to a differentiated care model out of the PEPFAR programs in Africa, which they started by thinking, "We have 35 million people in this world that need HIV medications, yet, we don't have the health systems to get them those. The way those health systems currently operated, so how do we do that?"

They had to make aspects of the health system more efficient. That might mean less medical care, but easier access to things like medications, and closer to the community, closer to people's homes to get medications without always going to the doctor visit.

That's how they've used that to scale up which may be right for a proportion of our patients. Yet some of the restraints of our current guidelines and metrics for programs and the way patients have to be monitored, can put a hindrance on that.

Also we have a lot of patients who have very complex medical comorbidities, very complex lives and may need a lot more than just that fast track type of HIV care where they can come in quickly for meds, get their meds, get some labs and leave.

Other people need really intensive visits, and so that's where I get into a little bit more...Beyond just this differentiated care and having fast tracks and easier places to get meds, how do we also have truly different models that become patient‑centered and programs can give to patients based on both patient preference and patient needs?

When I talk about different models of care, in the context of this talk, we talked a little bit about pop up or open‑access clinics for some of our highest needs populations who tend to cycle in and out of care, have lots of oftentimes social‑support gaps.

Again, whether that be with housing, or transportation, or just family support, or comorbid, substance use and mental health illnesses that also need to be addressed, or just someone who has a chaotic life, someone that it's hard to keep up with a schedule, "When is my doctor's appointment?"

This allows patients to come in on their own when is right for them. Often these types of models...There's one in San Francisco that I talked about, one in Seattle, and briefly a model that we had here in Atlanta for a little while. All of these models offer some other support.

There's often case management embedded a direct contact to someone in the clinic, whether that be a navigator or a clinician. Patients don't have to deal with our cumbersome health systems as they are at this point, even just trying to get through and get an appointment.

In the clinic out in Seattle and San Francisco, they're even given financial incentives to meet certain benchmarks, whether that be to get labs or to achieve some of the laboratory benchmarks that we go after like viral suppression.

Finally, filling those other gaps that the patients have, whether that be a meal while they're there, or intensive social‑work support to get housing or embedded within that a mental‑health provider or substance‑use care. That can all be done with one stop shopping as convenient as can be for patients.

Then more broadly, we talk a lot about just the overarching need for true integration of both mental health care and substance‑use care, in order to achieve optimal outcomes for our patients.

Jessica: You just mentioned there some elements that lead to success, but what are the different care delivery models that have shown success? We mentioned some that are failing, but talk to us about the success.

Dr Colasanti: The great thing in the field of HIV in particular, and thinking about care delivery and retention, how do we keep patients engaged in care.

The CDC has a great website. It's called a Linkage and Retention Compendium that has all the interventions that have been done over the years, summarize that have shown some benefit with retention or viral suppression or linkage to care.

We have a lot of those that give us a little bit of benefit. We don't have any magic bullet. A lot of those focus on, either the patient or the health system and how we can make the system a little bit easier for the patient.

Often with some sort of, either patient navigation, so using another human resource to help that person through the system. Or technology‑based, with mobile health‑type platforms to give the patients another platform to either communicate with the health provider, or get education, or have support groups.

A lot has been focused on that. Where we see a gap is often in actually looking at the structure of the clinic and the care team itself as well as the interaction with the provider and the people within the clinic, in that experience, and what's the impact of changing that on patient outcomes.

We have fewer data, but they're beginning to see some, at least on the fact that this is a real problem. We haven't seen data yet to show us what the solution is, other than the common‑sense solution, which has proved customer service and really making the patient the center of the care model.

Jessica: Talk to us about the customer service aspect of care for patients, and how it really affects the patient's care overall.

Dr Colasanti: We hear this all the time from patients. We know that stigma, whether external or internalized stigma and stigma that can be perpetuated by bad experiences within the health care system, that it drives patients away from care.

This is the one place when you're living with a stigmatized disease that a patient should be able to come with zero fears, and knowing that they're going to be treated well. Also, that it's just convenient for patients.

I'm a patient in the health system in 2021, with another chronic disease. It's really challenging to navigate. Every time I have to do it, I think about patients that don't have the means and the resources I do. I think to myself, "If I had a bad experience, if someone was a jerk to me..." I could very easily see how it's easy to turn the other way.

Elvin Geng has done a lot of great work in Sub‑Saharan Africa around this. I talk about this study in my talk. They actually found patients who were out of care. They asked them, why were they out of care?

Most of them said they fell out of care because something happened. Life happened. Something structural happened. A transportation issue. Work got in the way, or a family issue came up.

Sometimes it was something internal to them. They just didn't really care anymore, or they were feeling depressed. Then when they flipped the question around to the patient, same patients ‑‑ same patients that had said, "Why did you fall out of care?" ‑‑ and asked, "What would it take for you to get to go back?" All of a sudden the focus shifted to the clinic.

It was, "The wait times have to be less." "I can't be treated poorly," things like that. To me, that was eye‑opening to see. That there's all kinds of reasons we put our health care on the back burner. We all learned this probably in 2020 with our own health care.

Let's ask ourselves when the last time we got our every six‑month dental cleanings were. I imagine most of us missed those over the last year. If you're already having a bad experience, to then pull yourself up, so to speak, by the bootstraps and go back into care is next to impossible.

If you're having a really good experience, great. Common sense will tell you that will bring you back. I spend a lot of time thinking about that, and how we can improve that to get patients back into care when they inevitably will fall out because of a life experience.

These data actually are unpublished, but I got permission from the authors or the group that's doing the research to show some of their initial results. This is a group out of Houston. DrBich Dang and her group.

They showed that the initial experience between the patient and their clinician at the clinic ‑‑ the very first time the patient came to clinic ‑‑ did seem to have an impact on whether they were retained in care at six months or a year.

The great thing about that...It's what we struggle with in terms to deploy the interventions that we do have that are effective. Oftentimes, the question is when, and where, and how do we actually get these to the patient at the right time.

This new look at that patient‑provider experience, and a separation between those that had a perfect experience, and those that had a less than a perfect experience, gives you an opportunity to check in with patients immediately after that first visit.

If it wasn't good, maybe we need to swoop in and those are the patients that we need to put these other systems, and on other care models that I do talk about in the talk, around those patients. Or maybe talk to them about getting a different provider, or a different clinician, if that didn't mesh.

We feel in lots of ways, health care is becoming more of a convenience. Lots of patients in all walks of health care want a quick in and out. I do think that's true for some persons living with HIV. What we hear time and time again from our patients is that they want a relationship. They want people to care.

Take a look at the study from UCSF that I presented in this talk. When they asked patients about...This was from a care model where they were paying patients to do some of these things that we want patients to do, in terms of coming back and labs.

They said, "If you were to give up some of that money, what would you give it up for?" They would give up the most amount of money for a good relationship with their care provider. More than they would give up for easy access to the clinic, or transportation, or things like that. They want that relationship. They want someone to care about them.

That is going to be what ultimately gets us over the last hurdle to really provide optimal care to those that unfortunately, our system has labeled as challenging to retain and care or challenging to keep in care. It's more that we're missing the mark, and our systems are failing to keep them in care, rather than it being something that the patient is doing wrong.

Jessica: I don't think that we can talk about HIV care delivery in 2021 without mentioning the COVID‑19 global pandemic. How has the COVID‑19 pandemic affected care?

Dr Colasanti: There's lots of talks in the ACTHIV 2021 about COVID and HIV. A lot of this will get covered. In terms of true care delivery and where it affected us, it affected us a lot, especially at the beginning of the pandemic, in terms of patients just physically being able to get to the clinic.

Whether it was for fear, or for guidance from their own health care professionals to say, "We want you to stay home." We learned how to use Telehealth to some capacity, which had not been used broadly in HIV care. There is some existing evidence to show that Telehealth can improve viral suppression in certain populations.

What COVID did is it forced almost every health system to go ahead and implement it. Even though we had been talking about it for years, it forced the hand of health systems to do it. Now we have that tool. I still think we're figuring out how to optimize it.

Anecdotally, at least in our clinic, we found that both patients and providers have largely abandoned it as the pandemic has gone on and we've found safer ways to provide care. It's almost as if the provider and the patient both prefer the in‑patient care across the board. Though we do provide ongoing Telemedicine now to a much greater capacity than we ever did in the past.

There's clearly an avenue for it. It's up to us now to figure out exactly where and when to use that type of service. We saw lots of gaps in HIV testing actually. That was probably one of the most profound impacts of the COVID epidemic on HIV, and a lot of missed opportunities.

The focus all became on testing for COVID, when in fact acute HIV or late‑stage HIV can often present like COVID.

There was a study that I don't talk about in this particular talk, but out of Chicago, looking at HIV testing in emergency rooms, and showing how they kept all their HIV testing exactly where it had been pre‑pandemic. They picked up a lot of new HIV infections that other health systems in the area were missing.

That's certainly a lesson to continue our opt‑out HIV testing programs and scale those up, and think about models that integrate testing for multiple entities, whether COVID and HIV, all at the same time rather than against setting up these siloed systems where we just focus on one disease process.

Jessica: Is there anything else that you'd like to add, touch on that we missed?

Dr Colasanti: We covered most. I'll say just because I mentioned it briefly in the talk and it is such a hot topic right now in HIV care is the long‑acting antiretroviral therapy. The injectable therapy that is now approved and clinics are trying to figure out how to implement. There's some other talks around it at the conference.

They'll delve into it more than I had a chance to, but it's a new therapy that we're going to have to figure out how it fits into that differentiated care or different care model approach that I talked about towards the beginning of the session. It's important that we figure out how that fits into some of this differentiated care or different care models that patients may have.

This type of care is going to require more intense health system interaction than our usual care in a way, because patients have to come in at this point monthly for injections, whereas many patients may just be touching our health system once every six months for a visit. Otherwise getting medications mailed to them, or picking them up at a local pharmacy.

This requires more intense health system resources. We just have to figure out where it fits into the menu of care and make sure that we put resources behind it that match the intensity that this type of therapy requires to keep people on and engaged in care long‑term that may in fact be more so than our current therapies.

I would finish by saying we have more options now than ever before for HIV care. Yet, oftentimes, when a patient walks into care, they still get the carte blanche. This is the care you get, and then they only get other options if they fail that initial care model.

Where I think what we should be thinking about is at the front end, can we offer different care models that a patient can choose from? One that fits them and one that someone with a health background and some understanding of the issues that that patient is facing can advise which model may fit best for them.

I think that's where we're moving, kind of a choose‑your‑own‑adventure‑type of care so we can actually make care patient‑centered. We do a lot in programs such as Ryan White programs to make the care patient‑centered and to provide compassionate care, and to make it more convenient where we can.

We often lack the options that patients may want for various types of convenience throughout their care journey.

Jessica: Thank you so much for your time today, Dr Colasanti. We really appreciate it. I can tell you're passionate about compassionate care for patients, and we appreciate your time. Thank you.

Dr Colasanti: Sure. No, absolutely.   

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