June 10, 2020

“We Are Having to Work in Ways We Never Would Have Imagined”

Dr. John Weisman, Director of Washington state’s health department and Co-Chair of the President’s Advisory Council in HIV/AIDS (PACHA) made the above statement in the quarterly PACHA meeting last week. PACHA, first convened by executive order in 1995, comprises about 25 members including health care providers (one of whom is Academy Member Dr. Ada Stewart), people with HIV, state and federal officials, and HIV policy experts. PACHA meetings are open to the public via YouTube and meeting records and resulting recommendations are available here.

As PACHA’s first meeting since COVID-19 hit, the June 1-2 convening inevitably focused on its domestic impact on our HIV response. Health Departments across the country are racing to develop protocols for safe case counting, preventing infection and helping people exposed or living with either virus to self-isolate. Since the need for providers trained in HIV and viral diseases is growing daily, the meeting focused on how to maximize resources (human and material) across the country to counter these threats. And since COVID appears to be here for the long haul, the PACHA meeting acknowledged that this will, necessarily, be the “new normal.”

Vincent Guilamo-Ramos, a nurse practitioner with twenty years of experience in the Bronx, shared his view on this disruption of their daily lives. Although the state’s health department and AIDS Institute “were great” in their efforts to respond, their ability to get both HIV and COVID medications and treatment out rapidly where they are most needed, remains suboptimal. Given that New York is ahead of most other states in its response, this isn’t good news.

One potentially positive step emerging, however, is the sudden increased reliance on telehealth and other forms of electronic services. John Sapero – former HIV Prevention Chief for Arizona’s Health Department and chair of Phoenix’s Ryan White Planning Council – said that teleservices went from “zero to 60” overnight when COVID hit. Ada Stewart added that using telemed, phone calls, home visits, etc. to reach patients is now essential, especially in light of COVID. Traveling in public, including by public transportation, is not recommended for those highly vulnerable to COVID, including people with HIV. The possibility of accessing medical and social services without leaving home, therefore, is a valuable option.

Meeting participants focused a few hours on discussing the challenges and benefits of home-based services.  Johanne Morne, Director of the New York State AIDS Institute, said that Connecticut’s ADAP program has case managers working at home already. It not only gives them more time to spend with clients but the clients are also far more likely to show up for telehelp appointments, she reported.

Allowing more local health department staff to work at home can protect the physical safety of both staff and patients. It can also make the latter more inclined to access services if doing so doesn’t mean going to the health department in person. Instead, it offers them more privacy, saves them the costs of transportation and child care and allows them greater flexibility in choosing meeting times with one’s case manager — all factors that encourage their use of telehealth and telephones.

Health providers also potentially benefit from working at home. Rafaele Navaraez, a PACHA member and co-founder of Latinos Salud, described his work with undocumented Latino men who struggle every day to get enough work to put food on the table. Between March and April, Rafaele’s organization provided 852 HIV tests and 343 hepatitis tests to their clients but had nowhere to send them for ongoing care. In the local Ryan White clinics, he said, the HIV case managers are typically paid $18,000 per year and required to follow 60-70 patients each. Is it possible that — if allowed to work by phone at home at least part-time — they could save money on transport while scheduling client appointments based on the client’s access to a phone?

Finally, home-based access to a broader range of services can enable people to get their needs met despite stigma. The Michigan Health Department is sending mail-order condoms on request to home addresses because, of course, sexual activity happens despite social distancing rules. Lucy Slater of NACCHO, who attended the meeting to make a public comment, pointed out that telehealth is also being used for screening, counseling, case management and partner services. To reduce drug users’ risk of COVID and HIV, some syringe service programs are providing syringes and supplies via phone for curbside pick-up or delivery, and in the case of naloxone, even by mail.

Such innovative strategies can not only reduce HIV and COVID transmission risk, but also provides consumers a novel level of privacy while also offering providers more convenience and, arguably, may improve their work efficiency.

Diversifying work patterns is only one of many potential options for dealing with dual challenges HIV and COVID-19. And, obviously, all of these innovations will require public  funding if they are to stop and reverse most of the damage currently being caused by COVID and the chronic under-funding of our national HIV response.

As the meeting closed, PACHA Co-Chair Carl Schmid reminded us of the urgent need to fight to get as much of the HEROES Act – now pending in the Senate – passed and funded as possible. Ensuring that the Ending the HIV Epidemic (EHE) initiative continues to move forward is also as urgent as ever, as is advocating for passage of the HELP Act (HR 5806) in the coming year so that we will have enough HIV health care providers available to make the EHE a reality.

But the fact that the COVID crisis is forcing us think of, and try, new ways of doing this work is undeniable and very possibly a benefit. Richard Pascale wrote that “people are more likely to act their way into a new way of thinking than to think their way into a new way of acting.” Despite the challenges of these novel health care modalities, maybe we are seeing that assertion in action.  The Academy is committed to supporting our members and other HIV providers by making resources available to healthcare workers to track and implement best practices for these new health care modalities, including telemedicine.