Christian B. Ramers, MD, MPH, AAHIVS
Family Health Centers of San Diego
San Diego, California
Dr. Ramers attended medical school at the University of California, San Diego and completed combined residency training in Internal Medical and Pediatrics at Duke University in North Carolina. It was at Duke where Ramers saw his first patients with HIV during residency through special arrangements with the Duke Infectious Diseases Clinic in 2005. He has cared for people with HIV in diverse settings ever since. After his time at Duke, Ramers did an Infectious Diseases fellowship at the University of Washington (UW). While at UW he earned an MPH degree focusing on Global Health and worked with UW’s I-TECH program on HIV education projects in Tanzania, Mozambique, and Angola. Also at UW, together with the Northwest AETC, Ramers was given the opportunity to develop and lead a HIV-focused telehealth program, NWAETC-ECHO. The program was modeled on the very successful ECHO program from the University of New Mexico. Says Ramers, “I had the privilege to work with some incredibly innovative and inspiring collaborators in Seattle, Albuquerque, and throughout the Pacific Northwest who remain close friends and colleagues. Building things from scratch, we had the freedom to develop, tinker and refine the program to grow into a durable community of practice that is still thriving today and continues to inspire and train new HIV Specialists.” Ramers has provided clinical care and teaching in a diversity of settings throughout the world, including Tanzania, Mozambique, Angola, Namibia, Cuba and Guatemala. Ramers has a keen interest in the power of telehealth to expand the reach of mentoring and sharing of expertise beyond our local physical environments.
Today, Ramers works for Family Health Centers of San Diego, a network of Federally Qualified Health Centers (FQHCs) serving San Diego’s medically underserved communities. Ramers has worked at several sites within the network, including the recently established Hillcrest Family Health Center. This clinic provides cutting edge HBV, HCV, and HIV care and treatment as well as STD screening and treatment services, Pre-exposure prophylaxis (PrEP), and supervised hormone therapy for transgender individuals. It is also the primary teaching site for medical students, residents, fellows, and nurse practitioner training programs spanning HIV, HCV, and transgender care. In addition to Ramers, the clinic is staffed by four other AAHIVM-certified HIV Specialists; including a nurse practitioner, family physician, two Internal Medicine specialists, and occasional visiting faculty from UC San Diego School of Medicine. Family Health Centers provides primary and specialty care to roughly 1200 HIV-infected individuals, most at a centrally located Ryan White funded clinic. Many patients, however, are beginning to receive their care in their own community at their neighborhood medical home.
Says Ramers, “The majority of our patients are near or below the federal poverty line. At FHCSD, we implement several initiatives, including preceptorship programs, cross-training of support staff, an HIV-focused Family Medical residency track, and ongoing biweekly telehealth conferences in collaboration with the Pacific AETC to help support the integration of HIV care into several of FHCSD’s 20 other patient-centered medical homes. As an FQHC, these clinics are under pressure to provide care for a large pool of patients and to do so in an efficient, cost-effective manner. In this vein, we typically each see an average of 20 patients per day.” Because San Diego is just miles from the US-Mexico border, nearly all staff and providers are comfortable with English and Spanish. More than half of their patients identify as Hispanic/Latino, and many are undocumented and/or monolingual Spanish speakers. Although their core patient population has been aging, with many now approaching 60 or 70, they are still seeing new diagnoses, especially among young MSM of color. Disturbingly, the clinic still sees its share of AIDS diagnoses, mostly in individuals who never engaged in care, or never took an HIV test, despite ongoing risk. Approximately 10% of their patients are women, mostly Latina, who were infected via heterosexual transmission.
In his practice, Ramers has had tremendous success building a HCV treatment program by applying all the lessons learned from high-quality HIV care to the HCV epidemic. “From community-based point-of-care testing, linkage to care, harm reduction, patient navigation, providing a welcoming and non-judgmental medical home, to fearlessly confronting payers and pursuing patient assistance programs to secure therapies, we have built an ‘HIV-inspired’ HCV program. Most recently, we’ve brought liver fibrosis staging in house with a Shear-Wave Elastography machine that can provide point-of-care information on liver scarring and/or cirrhosis. It has been very helpful in streamlining the evaluation, staging, and approval process for HCV therapy, not to mention stimulating and rewarding to learn and incorporate into clinical practice.” Ramers’ practice has also taken a very proactive approach toward training interested primary care providers in taking on HIV care into their practices. A HRSA-sponsored Special Projects of National Significance (SPNS) grant has provided support for this initiative which targets both trainees and those already in practice. Says Ramers, “In our community clinic-based family medicine residency we reserve two slots per year in an ‘HIV track.’ Practicing primary care providers can also participate in the program, which uses a mix of in-person clinical training, self-study using web-based tools developed at UW’s www.hivwebstudy.org, as well as telehealth and case consultations.”
Ramers reflects on his past, “Growing up and coming of age in the San Francisco Bay area in the 1980s, I was deeply inspired by the chilling images and moving stories of the early AIDS epidemic. An interest in Microbiology and Infectious Diseases helped me stay apprised of advances in the field and I was fascinated with the transformation from ‘death sentence’ to manageable chronic disease during my medical training. When the stark disparities between access to life-saving anti-retroviral therapy in Africa and the United States became apparent in the late 1990s, I was sure I wanted to work towards equitable access for the world’s disadvantaged and underserved. More recently, given the prevalence of HCV co-infection in HIV patients, I have begun treating HIV/HCV co-infected and HCV mono-infected patients in the FQHC environment. In 2016, I strongly believe that HIV medicine offers a stimulating and rewarding practice, since it combines both the deeper long-term relationships of Primary Care with the cutting edge, intellectual aspects of a fast-moving specialty.”
Ramers feels strongly that it is a provider’s burden to collaborate with each and every patient to find a treatment regimen that will best fit with his/her lifestyle. Many patients have been trained to expect side effects, high pill burden, and off-target toxicities. Says Ramers, “Now, with so many great therapeutic options, it is no longer good enough just to attain an undetectable viral load, rather, a regimen must be customized to minimize side effects and maximize tolerability, while still maintaining virologic control.” Ramers tries to empower his patients to take control of their health by envisioning their future selves as free to live out their full potential without being held back by uncertainty, morbidity, fear of mortality, and stigma that still so often swarm the recently-infected. Ramers says, “I am explicit with patients that I haven’t truly done my job until their virus is completely and durably controlled and they are happy with the regimen and can see themselves sticking with it for a long time.”
“The true meaning of the word ‘doctor’ is teacher,” says Ramers, “And teaching brings great meaning and deep satisfaction to my medical practice. Whether it be educating students, residents, fellows, or primary care colleagues in the clinic, a dinner meeting, CME conference, or a telehealth session; I feel most alive and fulfilled when inspiring others to provide thoughtful, cutting edge, compassionate care to their patients. It has been extremely satisfying to introduce a number of providers to HIV care and to mentor them to become AAHIVM-certified HIV Specialists.” Ramers adds, “Taking up the fight to develop a HCV treatment program has been an intense challenge, filled with moments of both extreme satisfaction and maddening frustration. It has also been rewarding to dabble in public health, pharmaco-economic, and political advocacy domains.”
Over the past few years, Ramers has focused on the domestic HIV and HCV epidemics, but he says he sees himself returning to international work in the future, most likely in Africa. He has worked on HIV workforce capacity projects in Angola and Mozambique, and is currently part of an initiative to use telehealth to build capacity in Namibia, in collaboration with Project ECHO. Although access is improved, there is still much work to be done to build systems of care in the world’s developing countries. As HCV becomes more easily treatable and the affordability of therapies improves, Ramers would love to be involved in the rollout of more accessible HCV treatment programs in the developing world. Looking to the future of HIV care, Ramers says, “Researchers will continue to pursue better, less toxic, more convenient therapeutics, inch closer and closer to an HIV vaccines and perhaps someday a perfect ‘Cure Protocol.’ However, until that time, it will be community-based gumshoe HIV-friendly primary care that will continue to improve the lives of the many currently living with HIV. Prevention efforts like PrEP will become normative, and hopefully will make new infections rare. I believe that HIV will continue to integrate into primary care through a new generation of HIV-competent Residents, and a bold group of primary care providers who choose to take on HIV specialty. More than anything, I hope that the global HIV epidemic becomes more equitable with HIV-infected individuals in the Global South enjoying the ease of access, high-quality therapeutics, and good outcomes that those in the North do.”
When not working, Ramers is fully absorbed in family life, spending time with his wife and trying to keep up with the antics of his hilarious 11-year old son and adorable 7-year old daughter. He recently killed most of his front lawn and replaced it with raised garden beds that are now filled with organic vegetables. This has fed his renewed interest in ‘earth to table’ cooking. He also loves listening to and playing music and has cluttered his home with drums and guitars from around the world.
Asked why he is an AAHIVM Members, Ramers says, “I enjoy feeling connected to the community of HIV-treating providers, and greatly appreciate the advocacy and national solidarity that the Academy provides, both for HIV patients and HIV Specialists. I’m an Infectious Disease specialist, but also like to maintain the special recognition that AAHIVM’s HIV Specialist Credential entails as I think it distinguishes one from more hospital-based ID specialists who may not be actively involved in care of HIV patients.”
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