Addressing HIV/AIDS in 2013 and Beyond: Why the Future Demands Its Integration Into the Chronic Diseases Spectrum

In 2009, while I was on the medical faculty at Howard University, a 61-year-old, diabetic woman was referred to me by her primary care doctor. She was baffled about why she needed to see an infectious diseases doctor. During her hospital stay for intractable diabetes, per CDC recommendations she was screened for HIV but her doctor did not inform her about her new diagnosis. As frustrating for me as this was, I was thrilled she was referred for care and applauded the doctor for testing a 61-year-old woman for HIV. However, by the time I met her, HIV had severely damaged her immune system. She had AIDS. Had she been tested years earlier, this damage could have been avoided by early administration of medication .

Expectedly, once she began medication, HIV became the least of her worries. She began to feel better and consequently over the last four years has gained nearly 100 pounds. Because the HIV infection is completely controlled -- her virus is undetectable -- every visit we spend less than five percent of the visit time discussing her HIV status. The remaining 95 percent of the time is spent addressing one or more of the following issues: nutrition, strategies to increase physical activity, medication adherence and disclosure of HIV status. She isn't unique. My recent visit with her is a poignant illustration of why HIV prevention, care and treatment should be integrated into the traditional model of chronic diseases' prevention and management. Shifting our view of HIV to one of a chronic disease will reduce ongoing disease transmission because its integration into a holistic approach to health promotion and healthcare will reduce the stigma associated with the infection.

Any HIV provider across the country will agree the vast majority of HIV-positive persons on treatment are not medically suffering from HIV. Instead many suffer from the same environmental challenges as the rest of our society. They are often diabetic, hypertensive, sedentary and overweight. This reality has forced the emergence of patient-centered medical homes for HIV-positive people.

It is a model of care that is effective and expected to expand under implementation of the Affordable Care Act. At our clinic in southeast D.C., we have integrated a patient navigator into our clinical team. The navigator's role is to serve as an educator, confidante and facilitator of entry into care to ensure a newly diagnosed person is linked to our services within 24 hours. Oftentimes, this clinical linkage happens in minutes because the healthcare navigator is available to immediately walk to the person's location and begin a discussion about their healthcare. We implemented this process because the embarrassingly high rates of patients lost to health care required urgent attention. I suspect a review of primary care engagement for other chronic diseases like diabetes, cancer and heart disease would show similar concerns. Thus this model we have adopted for HIV care and treatment deserves consideration for all chronic diseases, not only HIV because it will reduce costly and inappropriate emergency department utilization and will foster sustainable relationships between patients and healthcare providers. Our clinical quality review demonstrated the value of the immediate linkage by a navigator because the interaction leads to better long-term health outcomes and consistent engagement in healthcare. Integrating HIV disease management into our conversations about and strategies for addressing chronic diseases would be a public health game changer -- not only medically, but socially. In fact, doing so would assist in answering the White House's call for strategies to reduce healthcare disparities.

HIV lingers because there aren't enough people thinking and talking about it in medical institutions and in the community. And when we do, it is in isolation -- within the HIV silo. This lack of attention and silence exacerbates stigma and shame associated with the diagnosis, which in turn discourages disclosure of HIV serostatus. Above all it discourages testing among patients and sadly, healthcare providers.

Consider the actions of the healthcare provider described above. The patient had been in care for diabetes for over 10 years, yet HIV was only considered when she was admitted at a medical facility with a routine HIV screening policy. Had this provider ever discussed her sexual history? If not, why not? Why didn't the provider discuss the diagnosis? More importantly was the provider aware of the treatment advances for HIV infection and that the majority of new HIV cases can now be effectively managed by a trained primary care provider? Addressing the HIV epidemic will require much more than promulgation and perpetuation of recycled messages, program strategies and silos. As the CDC has been reporting for nearly two decades , we have yet to move the needle on the rate of new infections. We can. And I believe the answer is chronic diseases integration.