July 18, 2012
By Susan Davis
Source: UCSF School of Medicine Website – Public Page – Patient Care Tab
Edward Machtinger, MD, with patient Vicki Blake Photo: Susan Merrell
When the AIDS epidemic first swept through San Francisco in the early 1980s, UCSF doctors quickly realized two key points. First, the primary patient population getting the disease – gay men – was already the target of significant discrimination, including in the health field. So those patients needed doctors who weren't just willing to treat them, but were passionate about it. Second, many of the patients were struggling with serious socio-economic issues in addition to their HIV.
In response to those needs, teams of doctors, nurse practitioners, nurses, social workers and other care providers at the University of California San Francisco (UCSF) and San Francisco General Hospital (SFGH) developed what became known as the "San Francisco model" of care for HIV-positive patients. That model emphasized treating patients with compassion and respect; providing an array of health and social services in one facility; and collaborating closely with the San Francisco Department of Public Health (SFDPH) and local community organizations.
Within a few short years, the San Francisco model became the global standard for HIV patient care, inspiring and educating communities around the world to emulate the city's practices and policies. Thirty years later, that model is still alive and well, but it has evolved in ways that reflect the changing nature of both the epidemic and the field of HIV research.
"The biggest challenge in San Francisco – and around the world – is identifying and bringing into care all HIV patients, in order to turn this epidemic around and perhaps stop it," said Paul Volberding, MD, a professor in UCSF's Department of Medicine as well as the director of the AIDS Research Institute there. "That's a big job. But it's something that can be imagined and modeled in this city, because of its small geographic size, its high standards of academic research and patient care and its very coordinated efforts."
Getting Patients into Care
SFGH's "Ward 86" was the first dedicated HIV clinic in the United States. A joint project of UCSF and SFDPH, the clinic has provided "one-stop" medical services since it was established in 1983 because "many HIV patients' lives are already disrupted," Volberding explained. "They may be dealing with poverty, homelessness, substance abuse, and mental illness, along with the HIV infection. Here in San Francisco, we have long understood that any system of HIV care has to recognize the social context of the disease -- what it means to take care of gay men, meth users, the homeless. We need to provide comprehensive medical and social care."
But these very issues can make it hard to find HIV-positive patients. "HIV is still a stigmatized disease," said Susan Buchbinder, MD, associate clinical professor in UCSF's Departments of Medicine and Epidemiology/Biostatistics and director of SFDPH's HIV Research Section. "It's a blame-the-victim kind of disease, because of who has been most heavily impacted: gay men, people of color and injection drug users." People may avoid getting tested because they're afraid of being stigmatized – or dying. Yet, when people don't get tested, they can infect others or delay medical care until they have late-stage disease.
The number of people who have been tested in San Francisco is relatively high. Researchers estimate that just 11 percent of the city's HIV-infected population don't know they have the virus, versus 20 percent nationally. That's largely due to the advocacy of local community leaders and the SFDPH. But even more testing is the key to getting people into treatment earlier.
In 2007, UCSF and SFGH pioneered a new way of increasing testing: offering it routinely to patients in the emergency room. This allowed clinicians to find HIV infections that otherwise would have gone undiagnosed. "These patients don't fit the stereotypical mold," said Brad Hare, MD, associate professor in the Department of Medicine at UCSF and medical director of SFGH's Positive Health Program. "They're not gay men in the Castro who may get tested regularly. Instead, they include more minorities, women, and heterosexuals -- people who hadn't recognized they were at risk or came from communities with even more stigma and fewer opportunities for testing. But once they were offered an HIV test, they could be diagnosed and brought into care."
Keeping Patients in Care
Once patients are in care, a big challenge is keeping them engaged with that care. In what is known as a "treatment cascade," HIV patients tend to disengage at certain junctures of their disease – at the point of being tested,getting CD4 cell count, receiving anti-retroviral drugs, suppressing the virus or continuing on treatment. "Each step offers an opportunity to do it better," Volberding said, "What are barriers? How can we reduce those barriers? Why do people disappear? At this point we know how to treat this virus. We have great, non-toxic treatments. Our challenge is not so much to develop the drugs now, but make sure they are used."
One way Ward 86 and other clinics in San Francisco have long kept patients in care is by treating them with respect. "What's special about Ward 86 is that we provide care to people of all shapes, colors and backgrounds, and we treat them all with the same level of respect, because we have a dedication and passion for the work," said Moupali Das, MD, assistant clinical professor in the Divisions of HIV/AIDS and Infectious Diseases at SFGH and director of research in the HIV Prevention Section of SF DPH.
At San Francisco General, Hare and his team also have developed a PHAST (Positive Health Access to HIV Services and Treatment) service that watches for signs of "poor engagement" among HIV patients, including patients who use the emergency room for treatment rather than primary care. "Once we identify someone who is HIV positive but not getting regular primary care, we reach out to them while they're in the hospital to figure out what challenges they're facing and which clinic might be best suited to meet their needs," Hare said.
UCSF and SFGH caregivers have also changed the kind of care they provide. "We've moved from providing hospice care and symptom management to preventing and treating the opportunistic infections that came with AIDS to, with the introduction of antiretroviral drugs in the mid-90s, controlling the HIV virus itself," Hare said. "HIV-positive patients can now live for decades. Aspects of HIV care are becoming similar to care for chronic diseases like diabetes or heart failure." That means health care providers can now treat non-HIV conditions in the primary care clinic. In one innovative program at Ward 86, where 30 percent of patients are infected with hepatitis C virus (HCV), patients can receive HCV treatment, along with HIV treatment, right in the primary care clinic. This model of primary care-based HCV treatment is now being used at other clinics, both locally and nationally.
Modern HIV care is also more carefully tailored to certain populations. Today UCSF and SFGH provide more services to Spanish-speaking patients, as well as incarcerated patients, veterans, women and patients over the age of 50, who may be dealing with issues related to HIV, HIV treatment or aging itself. Each of these populations has different needs. In recent studies, for instance, Edward Machtinger, MD, who directs the Women's HIV Program at UCSF, has found that many HIV-positive women struggle with very high rates of trauma that need to be addressed before their HIV can be effectively treated, a finding that could affect HIV treatment for women around the globe.
For years, HIV researchers believed that HIV patients shouldn't take anti-retroviral (ARV) drugs until their CD4 counts dropped to a low level, in part because the drugs had serious side effects. But in 2010, Ward 86 at SFGH and the City launched the world's first "universal treatment" initiative. Also called "community level care" and "treatment as prevention," this approach aims to offer every HIV patient in the city ARVs at an early stage of the disease, rather than waiting for signs of immune system damage. A new generation of less toxic drugs makes this safer. But also "we now know that HIV is a chronic inflammatory disease," Buchbinder said. "Just being infected – even if the patient has a high CD4 count - damages organs. Getting people treated is key to keeping them healthier."
UCSF researchers also now believe that treating people early doesn't just help individuals live longer; it reduces the rate of HIV transmission. HIV Prevention Trials Network (HPTN) 052 study, published this past May, found that among heterosexual couples, treating the still-healthy infected partner early reduced the risk of transmission to the uninfected partner by 96 percent. "The policy in many countries is to wait until the CD4 count is 200 - 350," Buchbinder said. "But this study found that even with CD4 count of 350 to 500, the risk of transmission drops. That makes universal treatment one of the most important strategies we have for slowing this disease in our communities."
The findings of this and other, earlier studies are so promising that New York City adopted a universal treatment initiative in 2011. The US Department of Health and Human Services also updated its treatment guidelines in March of this year to recommend universal treatment. Other cities, states, countries and international organizations (including WHO) are also now recommending treatment as prevention protocols. "What happens in San Francisco doesn't stay in San Francisco," said Das. "We have taken the leadership on this issue because we realize that what is good for the person is good for the community."
UCSF and SFGH are also involved in cutting-edge research on creating a vaccine against HIV, developing pre-exposure prophylaxis regimens, and discovering a cure for HIV. As with most HIV work at UCSF, this involves close collaborations with local researchers, as well as research centers across the country and around the globe.
"Here in San Francisco, HIV patients are our brothers and our sisters," Hare explained. "The epidemic affects us and we want to respond to it. And we can, because we have this amazing confluence of community response, the highest academic standards of HIV research and the SFGH mission to care for the uninsured and vulnerable among us."