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What Research is Telling Us About the State of HIV/AIDS in the United States: Interview with Expert Michael Horberg, MD

Michael Horberg, MD
Michael Horberg, MD

Kaiser Permanente recently hosted the 8th Annual HIV/AIDS, Hepatitis, and STI Conference. The event brought together physicians, advanced practice providers, research scientists, and other care providers, offering a constructive atmosphere for exchanging ideas, learning from national experts, and networking with colleagues from across the nation. For insight into the conference, we spoke with Michael Horberg, MD, national director for HIV/AIDS at Kaiser Permanente and member of the Presidential Advisory Council on HIV/AIDS.

 

CTH Blog:
Tell us about the 8th Annual HIV/AIDS, Hepatitis, and STI Conference you recently hosted.

Michael Horberg:
The goal of the conference has always been to bring together physicians, nurses, pharmacists, allied health professionals, and researchers to determine the latest knowledge and best practices in HIV/AIDS and hepatitis. We want to gather all of the people involved in HIV/AIDS care and share our best knowledge and practices.

The idea is to promote the key areas of learning in these fields: new knowledge and new medications for hepatitis; how to care for lesbian, gay, bisexual, and transgender patients; and new aspects of quality HIV, hepatitis, and sexually transmitted diseases care. Most importantly, we wanted to continue developing the Kaiser Permanente community of committed HIV and hepatitis care teams and community providers.

CTH Blog:
You presented a research study at the conference on the “HIV Engagement Cascade,” with participation of many of the HIV clinical and research leaders in Kaiser Permanente.  I understand this was presented earlier this year at the very important Conference on Retroviruses and Opportunistic Infections.  Can you give us some background for those unfamiliar with that concept?

MH:

For a while now, we’ve known that antiretroviral therapy (ART) can significantly improve health outcomes for people living with HIV. We consider ART to be successful when it reduces the viral load of a person living with HIV to undetectable levels. For years, clinical research has shown that people who have undetectable viral load in their blood are more likely to live long and healthy lives and are less likely to pass the virus on to others.

The CDC developed a standardized care order for how HIV care proceeds from diagnosis to ART success. It’s a series of steps or an engagement “cascade”:

1)    HIV diagnosis
2)    Linkage to HIV care
3)    Retention in care after diagnosis
4)    Prescription of ART
5)    Reaching an undetectable viral load

Each of these steps presents a challenge to an HIV-positive person and to the health workers who try to guide them through consistent care. One particular challenge for HIV-positive individuals is maintaining continuity of care throughout the process, especially if they lose access to health insurance.

CTH Blog:
Tell us about the findings of the research study you presented at the conference and what it means for our understanding of the engagement cascade.

MH:
We found that even if patients are diagnosed and linked to HIV care, it doesn’t necessarily mean they will start the appropriate medications and successfully reduce their viral loads.  Overall, the success of HIV care can be influenced by availability and access to clinical HIV care, available treatment for mental health, and access to other critical services like housing, transportation, and food. In the medical and public health communities, we need to do a better job of getting people from diagnosis to ART therapy and eventually, to an undetectable viral load.

CTH Blog:
How did you use Kaiser Permanente’s network of medical data to conduct this study?

MH:
Kaiser Permanente’s integrated electronic health record system enables us to look at people in all five stages of the HIV engagement cascade as a single, large study population drawn from multiple geographic settings and with age and gender groups well represented.

CTH Blog:
What are the biggest barriers to effective HIV/AIDS care in the U.S. right now?

MH:
The biggest challenges are getting everyone tested, into HIV care, and adhering to their medications, all of which will add up to better outcomes. At Kaiser Permanente, we do this exceptionally well: 89 percent of our HIV-positive patients are in HIV-specific care within 90 days, compared to 50 [percent] within one year in the U.S. overall.  Additionally, 69 percent of all our HIV positive patients have maximal viral control compared to 19-35 percent nationally. That means that our patients are getting the full benefit of HIV treatment.

It really comes down to good medical care work and investing in HIV treatment with multidisciplinary care teams. HIV-positive KP members have access to specialists, clinical pharmacists, nurse managers, case managers, and mental health care. We’re also aggressive about getting patients on the appropriate medications and keeping them on their regimens; we have 94 percent median treatment adherence among patients regularly in care and on antiretroviral therapy.

As a result, we’re achieving very good outcomes for our HIV patients and HIV mortality rates at Kaiser Permanente are half the national average. All of these elements are important on their own, but the reason we’ve had such success with HIV care is because we methodically combine treatments and procedures that we know to work into one effective toolkit.

CTH Blog:
What advances do you predict in HIV/AIDS care over the next 10 years?

MH:
I think the biggest advances will be in HIV case management – getting more people into care and on appropriate therapies. I see Kaiser Permanente playing a key role in exploring and advancing new best practices and providing the best care teams. We will also continue studying complications of HIV, especially through our clinical research and epidemiologic work. Our leadership and innovation in HIV/AIDS care will persist, and we will remain committed to sharing our best practices with private health care systems, clinics, and other care providers.

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