HIV Care Lagging in the Southern States

Heather Boerner

September 08, 2018

ORLANDO, Florida — Of the approximately 1000 people in northeastern Louisiana living with HIV in 2015, only 51% had achieved viral suppression, new data from the Louisiana Department of Health show.

One-third of these 1000 were diagnosed with AIDS in the first year after their HIV diagnosis, and another third had received no medical care in the previous year.

The models of care that people with HIV receive in urban and northern parts of the United States "really don't apply" to northeastern Louisiana, said Monica Johnson, executive director and founder of Helping Everyone Receive Ongoing Effective Support (HEROES).

So when it comes to achieving viral suppression, it's not surprising that the region lags behind metropolitan regions of the state, let alone national rates. In the same year, rates for viral suppression were 59% in New Orleans and 86% nationally, according to a recent national survey (Ann Intern Med. Published online August 21, 2018)

To turn the tide in rural areas, more money is needed and patients and rural healthcare providers need to be better educated, Johnson said here at the United States Conference on AIDS 2018.

"I would like to think that everyone who works in this field has the best interest of patients at heart," she told Medscape Medical News. However, "in my experience, that's not always the case."

Barriers to Becoming Undetectable

Johnson laid out the barriers faced by people in the region: limited education and literacy, which can lead to a lack of understanding of the medical language used by some providers; poverty and a lack of job options; stigma from family, friends, and even healthcare providers; lack of public transportation; and the limited number of healthcare providers.

And then there are persistent myths about HIV. For instance, Johnson said, one person told her recently that you can get HIV from mosquitoes. Another said he has clients who refuse to take their HIV drugs during pregnancy because of a fear that the fetus might be harmed. A third said that family members won't share plates or utensils with an HIV-positive family member, believing that HIV persists in saliva.

But one of the biggest challenges is one that physicians and providers have the power to change: the way they talk to patients and organize services to account for these multiple barriers to care.

Johnson described a client who, after being diagnosed with HIV, waited 2 weeks for an appointment at the only Ryan White Care clinic in the area, located in the next parish.

She had appointments to fill out intake forms to see if she qualified for Ryan White coverage, an appointment to see a psychiatrist, and an appointment to see a provider. Finally, at the fifth appointment, she got a prescription for HIV medication.

"It took her almost 2 months before she got her meds," Johnson reported.

"How long ago was this?" a person in the audience called out.

"This was last year," Johnson replied.

"What?" another person blurted out. "Wow!"

To improve viral suppression for people with HIV, rural providers need to focus their services around the needs of patients and help them get treatment as quickly as possible, Johnson said. And rural primary care doctors "need to know the basics" of HIV.

"All of them in our area have clients who are HIV-positive," Johnson, who has herself been living with HIV for 35 years, told Medscape Medical News. "They just don't know the basic stuff."

Care and Support Across the South

Many members of the audience said they were trying to address barriers in their own clinical settings. Some provide snacks and food for patients who have little to eat. Others said they are working to provide test-and-treat services so that a person diagnosed with HIV receives medication the first day.

The region might benefit from telemedicine, suggested Annette Chi Hughes, from HOPE Atlanta.

"It's so cute when people think we have real stuff," Johnson said, laughing. "That probably would work if patients had internet."

An audience member asked whether some of these patients could be covered by Medicaid. Louisiana didn't expand Medicaid, Johnson explained. Unless a woman is pregnant, it's unlikely any of those services would kick in.

"Money is a huge barrier," said Gina Brown, from the Southern AIDS Coalition, who is a former member of the Presidential Advisory Council on HIV/AIDS. "We're not going to get everyone to undetectable if there's not equal access."

"Why are we not angry? Why are we not fighting?" asked Lloyd Paige, a case manager from CareSouth Carolina, taking a cue from the opening plenary on activism.

"We need to band together with you to make things better," Paige told Johnson. "If you don't have the money, we need to band together with you to find the money. We can't let you fight by yourself."

Johnson, Brown, and Paige have disclosed no relevant financial relationships.

United States Conference on AIDS (USCA) 2018. Presented September 7, 2018.

Follow Medscape on Twitter @Medscape and Heather Boerner @HeatherBoerner

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