Navigating Through Barriers in HIV Management

William Short, MD, MPH, AAHIVS: In the United States, we still have roughly 35,000 to 40,000 new cases every single year, and it’s been that statistic for a very long time. And with all of the advances we have out there, I think it’s really important to get the message out that you really can prevent HIV with Truvada. And in addition to that, I think one of the hardest pieces looking at the prevention is when you look at those who are at risk. So, for example, African Americans. It’s estimated that a large percentage of them will actually need antiretrovirals for prevention and only 1% of that population is actually accessing it. It’s the same thing with regard to Hispanics and Latinos. So I think we need to do a better job of getting the message out to those hard-to-reach populations and trying to figure out, how do we actually reach those populations to get that message, to get them on therapy to prevent HIV acquisition.

So practical steps to get the word out about PrEP [pre-exposure prophylaxis]: So first I think it’s to reach providers who are taking care of patients who might be at risk for HIV. A large number includes primary care providers, obstetricians, gynecologists, health clinics, sexually transmitted disease clinics. That’s really where you need to get the message to. Because, again, in my clinic, I’m seeing largely patients living with HIV. So it’s very rare, unless they bring in a partner who is not living with HIV, that I would see that person.

You want to get that message out to them, get the education out. So that’s the first way. And then it’s really about getting out and getting community involvement. I think that’s really critical to bringing the patients who are at highest risk in to see you to access care.

So in terms of formulary restrictions, the science is trying to keep up with drugs that are coming onboard, and, as a provider, I look to figure out what’s best for my patient. A lot of the newer agents being approved are being approved for tolerability, for efficacy to prevent selective adherence to one drug or another. So I think one of things with having drugs on a formulary where there’s restriction is really a barrier to care. Patients can’t always take 2 or 3 drugs, right? I take care of patients every day and I know what they can and cannot do, and I’ve seen it over time. When a new drug comes out that I’ve been waiting for, and maybe right now it’s three pills a day, they’re so excited. Or maybe their family doesn’t know and they’re hiding 3 pill bottles. So having a drug like that which is restricted on a formulary is really a barrier to them getting the care they need. So it is something that really needs to be worked on.

I feel like I know what’s best for my patient. I’m sitting in front of the patient, the patient’s telling me what they need, and then I go to prescribe the drug and there’s this block. And then you call or you send in a prior authorization form which you have to do. It’s really not that big of an issue for everyone because sometimes, depending on your facility, you may have someone who can actually do that work for you. It’s all done behind the scenes.

But it’s when you get someone who will cause a rejection and really doesn’t understand, and you don’t know who you’re talking to. And if you actually take the time to call, a lot of times you’re met with someone who I feel is reading a script and doesn’t really understand. Patients don’t follow scripts, so you really need to know and be able to understand the patient factors that are running through my head when I’m constructing a regimen and why I’m doing that. So I think that’s why it’s so infuriating to a lot of practitioners.

In terms of unmet needs, I’m going to focus on 2 different areas. In terms of prevention, we have to really focus on that. In terms of prevention, the unmet need is how do we get that message to African-American MSMs, Latino MSMs, those hard to reach populations for whom we’re seeing more and more cases of HIV, and in young African-American MSMs? And we have a tool here. How do we get that tool to that population? That’s one of the biggest unmet needs in the prevention area. In terms of antiretrovirals for those living with HIV, I think the biggest unmet need is when you look at the cascade of care. So we’ve done better with getting people tested. We’ve done better with getting people linked to care. Our problem is, how do you keep people retained in care? How do you get that person to stay in care, to be followed longitudinally? Because what comes after being followed and retained in care is getting antiretrovirals and then getting viral suppression.

And that last bullet, and we know that when we look at the cascade your rates sort of drop down, but having that undetectable viral load is really what gives you all of the benefits we’ve talked about. And so, I think retention in care is one of the biggest things.

It’s one of the things I struggle with in my clinic. I’ll see someone, they do fine for a year, and then they’re gone. And at that time they’re gone, they’re off their medication and who knows what else is going on. You know, are they having problems with mental health, substance abuse, housing? You know we sit and worry about things such as antiretrovirals, but yet you have someone who doesn’t have a place to live, doesn’t have a place to stay, and doesn’t have food to eat. So, again, all of these things need to be embedded. So I think the single most important barrier for me, and really unmet need is, how to retain patients and care longitudinally.