Unpacking New Orleans' HIV Crisis: The Case for "Treatment as Prevention"
New Orleans, where I attend medical school, is an epicenter of the U.S. HIV epidemic. The city consistently ranks in the top three for new infections. As a future primary care provider with a special interest in reducing the burden of HIV, I wanted to tackle the underlying causes of New Orleans’ HIV crisis: stigma, lack of resources, and a need for more community-based HIV testing.
The number of new transmissions of HIV in a community is a direct function of the number of HIV viral particles present in that community. Decreasing community viral load protects the community at large, but it requires diligent work by public health professionals, epidemiologists, and the healthcare providers who prescribe the medications that suppress patients’ viral loads.
The most crucial step in decreasing community viral load is community-based testing so that people living with HIV know their status and can start medication. With a suppressed viral load, people living with HIV are essentially non-infectious. The dual benefit of starting treatment – to the person and to the community – is known as “treatment as prevention.”
Primary care providers are applying the “treatment as prevention” concept to other chronic conditions. The gold standard is the San Francisco model of HIV care, in which people who are newly diagnosed with HIV are connected to care and started on treatment the same day. At clinics and testing sites across New Orleans, our medical-student-run HIV and Hepatitis C Virus (HCV) testing program, Acacia NOLA, aspires to enact this model. HCV, like HIV, is a chronic infection that can have devastating consequences. One in five people with HCV will develop cirrhosis of the liver and one in twenty will develop liver cancer. Like HIV, a simple blood antibody test can tell someone if they’ve been exposed to the virus. Unlike HIV however, thanks to recent developments in testing and treatment, the virus is largely curable with a short course of antivirals, with few side effects or adverse drug reactions. Our program offers testing at homeless shelters, substance abuse treatment programs, and community clinics across the city. Under the supervision of clinic leaders, twenty-five medical students oversee ten sites, where they administer about 60 tests per month. Over the course of two years, we performed 963 tests, discovering 262 HCV antibody positives (a 27.2% rate). The substance abuse treatment centers had the highest antibody positivity rate, at 32.7%, followed by homeless shelters (25.9%), and community clinics (8.5%). Even in our community clinics, where people report few risk factors, our antibody positivity rate is much higher than the CDC’s estimate of the general population (3%).
Our program was founded on the premise that testing these populations would only be appropriate if our clients were connected to care. Of the 262 people who tested positive, 254 elected to get care. Through our partnership with Healthcare for the Homeless (HCH), we connect clients experiencing homelessness and those in treatment for substance abuse disorders to a primary care physician who can assess their medical needs comprehensively. This provides a “medical home,” or a home base from which our clients can interact with the various medical providers they might need to see for hepatitis-related care. HCH bridges the gap between the health care system and our clients. By leveraging our connections and bringing testing into the community, we have connected more than 100 people to services to confirm their preliminary diagnosis. Further, engaging with clients about a specific health concern like HCV has allowed us to open a dialogue about primary care more generally. That way, we can find and treat as many cases of HCV infection as possible while centering our clients in a primary care-focused medical home.