For more than two decades, the clinical team at the Einstein Medical Center has worked to prevent and treat HIV infection and AIDS.
Over that time, the message has changed from one of despair to one of hope.
Six years ago, the U.S. Food and Drug Administration approved a little blue pill that, if taken every day, can prevent HIV infection. Sold as Truvada, it's more commonly known as PrEP, for pre-exposure prophylaxis.
But Einstein caregivers have realized that many people who could benefit from the drug aren't getting it. So about six months ago, the Center developed a grassroots program focused on outreach and education for the community surrounding the North Philadelphia facility, neighborhoods that have some of the highest rates of HIV infection in the city.
To learn more about the program, we recently spoke to Jody Borgman, an Einstein internist who has been on the front lines of HIV and AIDS care since 1995.
To explain the program, I have to start with the medication. For people who are possibly at risk of getting HIV, either through unprotected sex or IV drug use, taking a medication called Truvada will decrease their risk of getting the HIV infection very, very significantly, almost to the point of a zero percent chance of getting HIV.
The medication has been available for some years, but recently, especially over the last year or two, the Centers for Disease Control and Prevention and other major organizations have started to promote it more, to try to get it out to more and more individuals and decrease the development of HIV infection among people who might be getting exposed to it.
We initiated the program here at Einstein not only to educate more of the general medical providers — and that includes the medical clinic here at Einstein, the adolescent clinic, the gynecological clinic — but also to go out to other community providers. Also, we're taking the outreach directly into the community, to local supermarkets, barber shops, churches, and other places. We want to educate people about this treatment and to see if people who might be at risk might be interested in getting started on the new medication.
We've been rolling out the program over the last six months. We've been getting great feedback from the doctors we're educating here at Einstein. They'd heard of the concept, but they really weren't promoting it to their patients. Now, they're more comfortable with what it's all about. As for the community, the feedback has been very good. Unfortunately, HIV infection has a lot of stigma attached to it. But when you start to let people know there are ways to prevent the infection, they're very excited.
Cost is not an issue. Most insurances will cover it. And for patients who do not have insurance, programs are available where we can get the medication for them at almost no cost.
It's an education issue. People aren't aware of it. There are multiple reasons that disadvantaged folks do not engage in health care, as opposed to people who have resources being more likely to engage and take advantage of what's available. There is definitely disparity of being involved and getting engaged with our system to receive good health care.
The community we serve is largely African-American and Hispanic, and for a long time it was not well-served as far as health care. That's why we're targeting those areas in our outreach. Now, any disparity in who gets the drug is not due to lack of availability. There are lots of good HIV care programs for everyone, regardless of race or income, in the city and in the state. The main issue is engaging people and getting them to come into care. Yes, there are concerns about insurance and costs. But, again, there are very good programs to help people get services if they engage.
For me, it's been an amazing career loop. I've been involved in the care of those with HIV and AIDS from the time prior to when no medications were available, to a time when treatments have become extremely effective, to the point where patients who are under treatment no longer have any issues or any risk of getting sick or dying from HIV. Now, most of the patients I deal with have their HIV under control. I often tell them that HIV is the least of their medical problems. Other things — like diabetes, high blood pressure, obesity — are more likely to cause significant health problems for them.
As far as the message, at this point, it's easy to provide a lot of encouragement. Many patients come in with a background or knowledge of what HIV used to be — that it could be life-threatening. The early treatments were very difficult. There were multiple pills that needed to be taken several times a day and that had a lot of side effects. We had a hard time getting patients to continue with treatment.
But now, we have excellent treatments that are one pill a day with very few side effects. That makes it easy to control the virus and keep patients healthy. So we can tell patients that HIV is something that is not going to be a long-standing health concern for them. They are going to be healthy as long as they can stay in care and take the medication.
We've seen that. Initially, in the community of men who have sex with men, there was dramatic change in behaviors when people realized that unprotected sex and multiple sex partners were contributing to the illness. If you look back in time, when HIV and AIDS became a reality, people made an effort to try to protect themselves — to use condoms more, for instance. Over the last several years, we've seen people revert back to old behaviors. People say, "I don't need to worry about this as much because there are good treatments available." That's where we see PrEP as being important. You can use this medication and prevent yourself from becoming infected.
It's been very rewarding to see the changes. I have patients I've been treating for over 20 years, who initially came in very sick. There were very few options for them. Thankfully, they were able to respond to early treatments. Now, we've progressed to easier regimens. And they are doing very well.
I think what people still are dealing with and having trouble with is that there is a stigma related to having HIV. It decreases people's interest in getting tested. They are worried they may actually be positive. Patients who know they are infected may not come in for care regularly because they are trying to ignore it, or they are having a hard time dealing with the knowledge that they got infected.
We need to continue to work to decrease the stigma of the illness. It is something that now can be easily treated and easily prevented.