For Gallup Indian Medical Center Ending the HIV Epidemic in Indian Country Means “Treatment as Prevention” and PrEP
At times, watershed moments in medicine are proceeded by something as tiny as a pill. For Dr. Jonathan (Jon) Iralu, who began his career at Gallup Indian Medical Center at the peak of the AIDS epidemic, antiretroviral treatment (ART) was nothing short of a miracle.
According to Jon, before ART arrived at GIMC in 1996, it was not uncommon for patients to receive a diagnosis and then not survive a month. With this new treatment, however, patients who were once terminal were able to turn a corner. Today, people living with HIV can expect a near-normal lifespan.
According to Jon, who has spent his almost three-decade career researching and treating infectious diseases, “we are living through another critical turning point in HIV care. Today, we have the ability to prevent the spread of HIV by using treatment as prevention and through expanding the availability of pre-exposure prophylaxis.”
Treatment as prevention
For Jon and his colleagues at GIMC, using treatment as prevention means removing barriers to care for HIV+ patients via a comprehensive homecare program. It also means supporting patients with medication compliance, so that they can achieve an undetectable status – in turn preventing the spread of the disease to others.
Expanding access to PrEP
Preventing the spread of HIV, also means working to expand the availability of pre-exposure prophylaxis (PrEP) – a medicine that prevents high risk individuals from getting HIV.
Since 2016, Jon and his colleagues have been working to increase the availability of PrEP on the Navajo Nation. But this work has not been easy. The Navajo Nation, like many other Tribal Nations, is resource challenged and staff are stretched thin. According to Jon, the GIMC team realized quickly that if all patients who could benefit from PrEP had to visit a physician every 3 months, primary care doctors would soon be overwhelmed.
To address this, Jon and his colleagues designed their program to accommodate fewer one-on-one visits with providers of record. How it works: primary care doctors are trained to rapidly identify and refer patients who may benefit from PrEP to the program, where the majority of treatment and monitoring is performed by HIV Pharmacists. HIV Pharmacists regularly visit with patients, set up testing for STIs and viral hepatitis, monitor patients for any medication side effects, and help patients overcome any barriers to medication adherence. HIV Pharmacists at GIMC even mail medications to patients’ homes and do telemedicine visits. This model frees up physicians of record who typically only see a patient once per year.
Recruiting patients via innovation, colleagues, and community partners
To encourage those who might benefit to access PrEP, Navajo Nation clinical and public health staff took an innovative approach – creating pop-up adds on a popular dating app. According to Jon, “ads would display for app users who both identified as American Indian and lived within the Nation’s clinical catchment area. Not only did the ads help get the word out among Two Spirit and LGBTQAI+ community members, but it also helped our patient population grow.”
To recruit people who inject drugs, Jon and his colleagues rely on GIMC’s medication-assisted treatment (MAT) program. “The majority of our family medicine and ob-gyn providers are trained on prescribing MAT, screening patients, and referring to the PrEP clinic. We also get a fair number of clients from GIMC’s Transgender Care Clinic too, which offers PrEP to everyone who comes through the door.”
Finally, GIMC has a community partner – a detox and rehabilitation center in Gallup – that connects community members experiencing substance use disorders and homelessness with social and medical services, including GIMC’s program.
“Via these methods, and a few others,” explained Jon, “we are able to systematically reach several populations who research has shown benefit most from PrEP at times they would naturally access services.”
Expanding your clinic’s PrEP and HIV treatment offerings
To expand your clinic’s PrEP and HIV treatment offerings, Jon recommends that you:
1) Identify clinical champions interested in expanding your services.
“Seek out a physician, public health nurses, and/or community health representatives who are passionate,” says Jon.
2) Work with primary care to spot patients who might be struggling with SUDs.
Then screen individuals for STIs, HIV, and introduce them to the idea of PrEP.
3) Screen for STIs and HIV in the emergency room.
“We know that roughly half of our patients never show up in primary care” says Jon. “Rather, they access emergency or urgent care services. Committing to offering screening and referral in the ER often helps reach those in the community who might benefit most.”
4) Make your EHR work for you.
To aid with screening and referral, work with your EHR folks to allow common STI tests (like gonorrhea, syphilis, and chlamydia) and HIV to self-populate in a patient’s chart, with the click of a button.
5) Have a standing screening protocol in place.
According to Jon “this makes it simple for docs – whether they are in primary care, the emergency room, or urgent care. Streamlining and bundling tests is really the way to go.”
6) Address stigma.
“The first interaction I have with an HIV+ patient is key,” said Jon. “During this interaction, my goal is not to talk about CD4 counts, viral loads, or any technical details. I even keep the physical exam short. Rather, I focus on gaining my patient’s trust and reassuring them that I will care for them as a human being, like I would for anyone else, independent of the risk factors that may have led to their infection. This philosophy is something we instill in staff.”
7) Develop a homecare component to your program.
To allow you to de-medicalize the care experience for people living with HIV, offer culturally appropriate services, and address patients’ medical and social needs while removing barriers to care.
8) Join the University of New Mexico’s HIV ECHO sessions and Indian Country ECHO’s PrEP ECHO sessions.
Here you will participate in didactic and case presentations, receive recommendations from peers and a multidisciplinary team of specialists, and join a learning community of dedicated I/T/U providers committed to growing clinical capacity so every patient across Indian Country receives the care they deserve.
“I want to see basic HIV care and PrEP available at every clinic across Indian Country,” said Jon. Through online HIV and PrEP ECHO sessions, we’ve trained lots of primary care providers and pharmacists on treating HIV.”
For Jon and his colleagues at GIMC, the next watershed moment in medical history may be building momentum– ending the HIV epidemic in Indian Country. Oddly enough, it may be proceeded by something less tangible than a pill – an ECHO.
