By Stephen Spotswood
WASHINGTON – When the first Infectious Disease Clinic took place at the Washington, DC, VAMC in 1985, only a handful of HIV-infected patients took advantage. In fact, the disease hadn’t even been named “human immunodeficiency virus;” that would happen the next year.
Today the clinic is a permanent part of the medical center, caring for 1,200 veterans with HIV, while the VA as a whole treats approximately 27,000 patients living with the disease.
What has occurred at the DCVAMC clinic is representative of how HIV and acquired immune deficiency syndrome (AIDS) treatment has changed across the VA and federal medicine. Spread of the disease, along with improved treatment protocols, have caused the clinic to grow and evolve during the past 30 years in ways that never could have been predicted.
The ID Clinic provides consultative services for patients suffering from the entire spectrum of infectious diseases — latent TB, microbacterial infections, STDs and hepatitis, to name a few — but HIV patients make up the bulk of the caseload.
One reason is that the clinic not only treats the patients’ HIV but also manages their primary care.
“That’s a model we’ve preferred because of the complexity of caring for these patients,” explained Debra Benator, MD, the clinic’s director, who joined as a fellow in 1992.
The decision was made to keep as much of the patient’s care in the clinic as possible because of the complexity of the drug regimens and the possibility of adverse interactions. Another is to better treat common comorbidities, such as hepatitis C (HCV).
To achieve this, the clinic has brought in specialists to cover as many aspects of patient care as possible.
“The model of our clinic has been one of the PACT (Patient-Aligned Care Team) approach,” even before the model officially existed, Benator said. The clinic’s team includes a nurse practitioner, medical staff assistant, social worker and clinician. It also includes an HIV psychologist, HIV pharmacist, HIV hepatologist and an HIV diabetologist, who provide services at least once a week in the clinic.
The clinic leverages its location in the seat of federal power by including regularly-visiting physicians who are employees of other agencies in the region — the Food and Drug Administration, the National Institutes of Health, Health Resources and Service Administration, as well as George Washington University, which has a fellowship education program with DCVAMC.
“These are infectious disease specialists who are experts,” Benator said. “They may do work in policy or drug regulation or other types of areas but are trained in infectious diseases. They’ll do a half-day a couple times a month to care for patients in our clinic.”
Also, four or five fellows from GW are attached to the clinic under supervision of the attending physician.
“It’s quite a busy place,” Benator said. “And that’s been a difficult balance in some ways, because our exam rooms are packed. But we’ve achieved the best possible care for our patients.”
Helping Patients Navigate Care
The reason for the increasing number of specialty physicians attached to the clinic is that more and more HIV-infected patients are living longer, healthier lives. HIV is no longer the death sentence it once was, which means HIV-positive patients will have to deal with the universal ailments of growing old.
In the late 1980s and early 1990s, the patient load was relatively small — just a few hundred — and the mortality rates were much higher.
“We lost many of them, and we had lots of patients hospitalized,” Benator said. With standard antiretroviral therapy (ART) in its 18th year of use, that mortality rate has shrunk significantly, with patients diagnosed early achieving a normal lifespan with therapy.
“HIV is a chronic disease that they manage, and they live their life,” Benator said. “In 2011, close to 70% of our patients had a viral load less than the limit of detection. That’s the goal for each of our patients — that they have antiretroviral therapy and full virologic suppression for life. We reduce the risk of HIV-related opportunistic infections, reduce the risk of comorbidities and have a meaningful impact in suppressing HIV indefinitely.”
About 20-30% of patients continue to have higher viral loads, however.
“The news is good and quite dramatic in terms of improving data associated with morbidity and mortality,” she explained. “But there’s a population we don’t reach successfully. They’re either not engaged in care or not responding to antiretroviral therapy.”
A number of factors are at work: The standard treatment regimen isn’t as effective for every patient. Also, drug and alcohol dependence make it difficult to follow a treatment regimen, as do some mental health diagnoses. As many as 50% of HIV-positive patients have a mental health diagnosis, with depression being the most common.
To better reach these harder-to-treat patients, Benator has hired an HIV nurse navigator whose sole purpose is to help guide them through care. The nurse meets with patients regularly, has regular phone calls and sets up text messaging medication reminders. She calls to remind them of appointments and, if necessary, connects them with social services and other programs at the medical center.
Still-existing stigma surrounding HIV infection and treatment should not be discounted as an additional factor impacting treatment adherence, Benator noted. “In the days gone by, there was greater skepticism and distrust of the medication and worry that those were more toxic than helpful. I think the majority of patients have moved beyond that,” she recounted. “But there’s still stigma that impacts patient behavior. We have quite a long way to go in many regards.”
Benator said she hopes a more intensive approach with the nurse navigator in educating patients about the disease and treatment options will help combat some of that stigma.
Along with improvements in HIV therapy, another area of care that has improved significantly during the past few decades is the ability of the ID Clinic to collect and analyze data. It’s this meticulous data collection that allowed the ID Clinic to recognize that the number of patients with an undetectable viral load has more than doubled in recent years. An analysis of HIV-1 RNA and CD4 patient counts from 1999 to 2011 shows that the number of patients at the lower limit of viral load rose from 27% in 1999 to 72% in 2011.
The study, published in February 2013, credits much of this improvement to the advantages of having a multidisciplinary team providing patient care.
Benator said there are still blind spots to fill in. The clinic is part of the DC Cohort Longitudinal HIV Study. The study will collect data from 10,000 HIV-infected outpatients from major treatment centers around the city.
“This will help inform the epidemic city-wide,” Benator explained. “The goal is understanding care not just among our patients but in the city more broadly. We already have some interesting data from the DC cohort. We’re learning where in the city the high risk behaviors are.”
With the recognition that treating comorbid conditions can have a dramatic effect on the health of HIV-infected patients, the ID Clinic is putting considerable resources behind one of the most common comorbidities, creating a separate treatment clinic for patients infected with both HIV and HCV.
“This is a new paradigm in HCV. We wanted to take a much more aggressive approach in treating patients,” Benator explained. “We’re addressing all of their comorbid conditions, but the number one concern is hepatitis C.”
About one-fourth to one-third of the DCVAMC’s HIV patients are coinfected with HCV, which means they experience more rapid progression of liver disease and do not respond as well to interferon.
New HCV medications that do not rely on interferon are showing promising results. In the meantime, creating an HIV/HCV clinic inside the ID Clinic allows Benator and her colleagues to better craft a regimen from the treatments which are currently available and to keep a close eye on patients’ health, especially their liver function.
“We want to cure as many patients with hepatitis C as possible, because that has a huge impact on morbidity and mortality, particularly as it relates to liver disease, but additionally the risk of diabetes,” Benator said. “That, perhaps, is our highest priority.”