90 – 90 – 90 is a treatment target to help end the spread of AIDS. This is an idea that by 2020, 90 percent of people living with HIV will know their status, 90 percent of people who know their status will be on antiretroviral therapy and 90 percent of people on antiretroviral therapy will achieve viral suppression.
Dr. Cassandra Pierre and Paul Goulet join the show to discuss the quality of infectious disease care offered at Boston Medical Center, World AIDS Day (December 1st) and how Boston Medical Center is the largest HIV/AIDS program in the New England area.
Cassandra Pierre, MD
Dr. Cassandra Pierre is a specialist with Boston Medical Center’s General Infectious Diseases practice and an instructor of Medicine at the Boston University School of Medicine. Dr. Pierre completed her internal medicine residency training as well as her fellowship at Boston Medical Center. Her research interests include the risk of occupational exposures to blood-borne viruses among health care workers in developing countries, biomarkers assessing the tuberculosis treatment outcomes and the interaction between tuberculosis and HIV and she specializes in the treatment and diagnosis of patients affected by the AIDS virus.
Paul Goulet has more than 28 years of experience working in health policy and consumer advocacy. He currently serves as the Program Manager for the Special linkage and Retention Team (ARCH Team) at the Center for Infectious Disease at Boston Medical Center. He is the chair of the New England Association of Gay and Bisexual Men’s Health covering six New England States and also serves on the board of the National Quality Center, Consumer Advisory Council.
Melanie Cole (Host): The 90-90-90 treatment target to help end the spread of AIDS it the idea that by 2020, 90% of people living with HIV will know their status, 90% of people who know their status, will be on antiretroviral therapy and 90% of the people on that type of therapy, will achieve viral suppression. My guests today are Dr. Cassandra Pierre. She is a specialist with Boston Medical Center’s General Infectious Disease Practice and Paul Goulet. He is the program manager for the special linkage and retention team, ARCH team at the Center for Infectious Disease at Boston Medical Center. Welcome to the show both of you. So, Dr. Pierre, what’s going on in the world in regard to HIV and AIDS today? Discuss a little bit about the remarkable success we have had over the past two decades in reducing HIV associated morbidity, mortality, transmission. Kind of give us a little summary of what’s going on.
Dr. Cassandra Pierre, MD, MPH (Guest): Good morning Melanie. Thanks for having me on. The past few decades have really been a remarkable time in seeing an explosion in the number of safe and easily tolerable medications that patients can take. In the pre-antiretroviral era, we saw that people who were diagnosed with HIV had about a 12 – 12 ½ year life expectancy. And now, people living with HIV and AIDS are expected to live a life expectancy similar to that in the place that they live for example here in the United States our average life expectancy is around 78 years of age and we expect that many of our patients will live to that age and maybe longer with the medications that we have. So, we are seeing a significant decrease in mortality. We are also seeing an improvement in morbidity; so less diseases, less chronic illnesses, however, with longer lives, our patients are leading; we are seeing some things that we hadn’t seen before. More cardiovascular disease, for example, higher rates of cancer and so it’s important for our patients to remain well-connected to us in care even if their viral loads are suppressed.
One really exciting thing I just wanted to mention, you asked about transmission, is that the more people we get on medications, the more people we get suppressed on antiretroviral medications; we are now seeing that people – for people who are undetectable, it is becoming virtually impossible for them to transmit the virus to their sexual or needle-sharing partners and in some places, we are calling that U=U or undetectable = untransmittable. And that is really exciting. What it means is that getting people suppressed is going to halt further transmissions of HIV.
Melanie: And Paul, what do you see as some of the major challenges that still remain for young people; having that conversation about AIDS and HIV status? Are they still asking these questions and discussing this topic?
Paul Goulet (Guest): Well I think it’s – I come from a- I’m HIV positive myself and I have lived through 35 years going on 36 years of being an HIV positive male and for a long time, I was doing a lot of – I was having a lot of conversations with young adults and it is just really interesting to sort of see the history or should I say the lack of history that young adults have about the AIDS epidemic and sort of the statistics that have happened to people who have passed away, people who struggled with severe illness. So, to have that conversation today, it needs to be really framed in a different way because I think a lot of youth don’t have that experience, have never lived in that age when they saw their friends pass away with being really sick. So, I think a lot of the times now, it’s really an interesting conversation to have because I think in our youth, as when all of us were younger, we always thought that we were indestructible, and nothing was going to bother us, so we were going to live forever. But the conversation is really different now. I think the conversation is about having really an honest conversation with youth at a young age about the transmission of sexually transmitted diseases, such as HIV and other diseases and in that context. One of the things that I have really found interesting is in my conversations with young adults today, they just think oh, I just have to take a pill and I’ll be fine. So, it has really reversed the conversation. It has almost become because HIV has become a chronic manageable disease; a lot of younger folks don’t think that it’s anything that they really need to talk about because there is medication that takes care of it. But on the other hand, the young folks who are talking about HIV and AIDS today, don’t have the experience of someone from long ago. So, it is really a different conversation.
Melanie: Paul, do you think that there’s still a stigma when you do have these conversations or when you tell people about your status? Do they recoil? Do they look like they feel sorry for you? Is there still some sort of a stigma that you can tell us about?
Paul: There is absolutely a stigma and we see that stigma as an intake coordinator here, as the intake manager, as the program manager. One of the first people that people see is – of people who come to see me, and I do all the intake for people who are newly diagnosed, people who are transferring their care or people who are re-engaging in their care and we are finding, I’m finding that a lot of people especially from other countries and other populations, there is a very high, high rate of stigma. People don’t want to talk about their status, because of religious issues, there are social issues. So, I don’t think we have done a really good job at helping to sort of tear down the walls of stigma. I’m always a person who says if we keep hiding our status, then we are creating our own stigma. We need to normalize that this is just another illness, just like some other illnesses that can be treated just as well. So, I think the stigma, there is still a large, large degree of that happening in the world today and unfortunately, that’s also keeping people out of care.
Melanie: Dr. Pierre, I mentioned in my intro about the 90-90-90 treatment target to help reduce the spread of AIDS. So, tell us a little bit about this plan and how realistic is it?
Dr. Pierre: Of course. So, 90-90-90 was a concept that was created originally by the UN - United Nations program on HIV and AIDS in 2013 and as you mentioned, at the intro, it is about getting 90% of people living with HIV tested and aware of their status, getting 90% of those on antiretroviral therapy and 90% of those on treatment with complete serologic suppression meaning that they have undetectable viral loads meaning that they cannot transmit to their partners. And this goal was created with the view of having the elimination of HIV transmission, the complete elimination of HIV transmission and creating the first AIDS-free generation by the year 2030. So, it is very ambitious. However, we really do believe that it is feasible. Many of the world’s countries are being ramped up for increased testing. Many of our previous treatment barriers, for example, needing to have an immune system that was low to begin starting treatment have been removed. We now recommend that all people start on treatment as soon as they are diagnosed. And so, we are getting closer to getting the world’s population on treatment, getting people tested and getting people suppressed.
Melanie: So, which countries have made remarkable progress towards this goal and which countries are still struggling, Dr. Pierre?
Dr. Pierre: Well, not surprisingly, when you think about who has resources. Countries in western Europe are really the places where we are seeing either marked strides towards reaching 90-90-90 or achievement of 90-90-90. So, places like Scandinavia for example, Sweden I believe is the first country to reach the 90-90-90 target. A lot of the western European countries have the luxury of having small populations of people living with HIV, but they also have very high engagement in the healthcare system. And so, patients have insurance, patients get healthcare and they follow up to their visits and so these countries have been able to achieve those targets or are close to achieving them. The places that need a little bit more help, well, unfortunately, we do live in one, the United States. We are not quite at the 90-90-90 target. We have engaged maybe 75% of our patients in care, but we fall short in terms of getting those patients suppressed. Actually, I want to go back a little bit to thinking about countries that have achieved the 90-90-90. We think about countries in sub-Saharan Africa as needing help toward achieving it but there is one country actually, Botswana that has made also marked strides in terms of almost getting to 90-90-90. They have put in a lot in their healthcare infrastructure, not just for HIV but for other chronic and communicable diseases and they are very close to achieving a 90-90-90. They are a model for the world, but also regionally, for other countries such as South Africa, Zimbabwe, and places in eastern Africa where we are further away from achieving the 90-90-90, although we believe it is still feasible.
Paul: I would also like to add to Dr. Pierre’s statements. So, in Botswana, I think it is really important to remember that 25% of adults in Botswana are HIV positive in the age range of 16-49, so that is pretty amazing that they are leaders and especially in the Botswana area and also Kenya, I think is another place where they are having much success and they have 1.5 million cases and 90% of those people are covered with generic drug distributions. So, I think those are really important things to remember about the size of the population that is affected as well and how well that they are doing at achieving the 90-90-90 goal.
Melanie: It is important information and Dr. Pierre, tell us about the quality of infectious disease care offered at Boston Medical Center.
Dr. Pierre: Well obviously, I’m a little bit biased. But we have a wonderful system in the infectious disease care center. We offer – we view ourselves as a medical home for those patients living with HIV and AIDS. We have case management, we have access right in our clinic to specialized providers. We have psychiatry, we have substance abuse providers, we have many groups of people who come together to provide excellent comprehensive healthcare for our patients. Many people think that we are just HIV, we are not. We also offer group care in many different areas, for other chronic infectious diseases, hepatitis B, hepatitis C, other viral and bacterial diseases or infections in other immunocompromised populations as well as offering care for travelers. But we have access to and care right in our clinic to world-class physicians who are leaders in research and advocacy in their fields. We have knowledgeable and experienced nurses, case managers, as I have already mentioned and a host of other supportive staff. So, we have amazing care and that is actually supported by our high patient satisfaction scores that we receive. So, as I said, I am very partial, but I think that we have a very unique setup in our clinic, different from many other places in Boston where we have access to all of these amazing resources right in our clinic.
Melanie: And Paul, tell us about your role as the program manager, as point person or point of care person for patients as they are tested and receive their results?
Paul: Sure, so I think we have a really unique perspective here as Dr. Pierre was saying at Boston Medical Center. So, as the person who does all the intake, who conducts all the intakes for people who are new to care, people who are re-engaging in care or people who are newly diagnosed; I think one of the special things that happens here is it is very personal. As a person living with HIV, I get to meet the people, I get to tell them their diagnosis but at the same time, I also get to tell them my story. So many people who enter care here or who are entering care for the first time come with a great deal of fright and of anxiety and there are still again we talked earlier about the stigma, we talk about life expectancy. So, I think my role here is very personal. My goal here is to keep people in care, to re-engage as many people as possible and also to make sure that newly diagnosed people are entered into care here.
So, telling my personal story, listening to their story, telling my personal story and actually seeing a little bit of their reaction change when they go like ah, I can live my life, I can have my dream, I can still do what I want to do. And part of what I do is I do what we call an assessment of acuity where we find out where people fall. Are they a high acuity? Do they need a lot of services? Are they basic acuity? Are they moderate acuity? So, we do as Dr. Pierre said, we do everything here. I make sure that they are – they have a medical appointment with an ID doctor within two weeks and any other things they need. They have their own nurse. They have their own medical case manager. And so, we follow, my role is to follow those folks through the care process to make sure they make their first appointment, to make sure they make their second appointment and also to link them in with our – if they need intensive case management, to hook them up with a team of people who will help them achieve what their goals are as well as helping keep them into care.
Dr. Pierre: And I would like to add that this system seems to have been really successful. We have patients who come in on the strength of getting recommended or referred from other patients who have had their intakes at BMC’s ID Clinic and they say you know I heard that this is a good place to come to, my friend or my colleague or my partner felt really comforted here and so I felt comfortable enough to come in and finally link to care or in the case of those who may have fallen out in other clinics, come back to care at Boston Medical Center to get my care because of the great things that I have heard. So, I think Paul’s intake process has been really wonderful and well-received by patients and important for our linkage and retention to care.
Melanie: So, Dr. Pierre, tell us a little bit about World AIDS Day December 1st and what do you see is the need for active research and development of community-friendly interventions. Give us a summary. Wrap it up for us, what you would like everyone to know about advances in HIV care and AIDS and this 90-90-90 treatment target.
Dr. Pierre: Okay, well that’s kind of a tall order to kind of wrap everything all together. World Aids Day, it actually came about in the early 80s and it was actually the first World Health Day ever to be celebrated and it wanted to call attention to the issue of AIDS and the importance of getting tested and over the years, that focus has changed. It has changed from getting tested, acknowledging the disease to removing stigma to focusing on the rights of those with HIV and now finally it has moved toward the view that we can eliminate, eradicate HIV transmission and again, create the world’s first AIDS-free generation. We have a long way – we have a little bit of way to get to the goal of eradicating stigma and getting to the world’s first AIDS-free generation, again, we believe it is achievable.
Part of the research that needs to go into that is well a lot of social research and getting people tested, removing stigma in communities also in how to address healthcare disparities that keep certain people disenfranchised, keep them away from health insurance, from comprehensive centers of care where they can receive patient-friendly, patient-centered care. There are certain populations that we know we are missing. For example, black men who have sex with men. How do we engage those communities when they see themselves as disenfranchised and stigmatized? So, there is a bit of work that needs to go still into testing, linkage and retention. But we are doing some of that research right here on campus and of course, it is going on all over the world.
Of course, the ultimate research is working on a cure for HIV and there is some preliminary work going on in that field that has been really promising. I tell my patients, and this may sound irresponsible, but I don’t believe it is and many of my colleagues feel the same way. We believe that there will be a cure in our generation, so that is obviously the ultimate research goal. But for the time being, we know that the tools that we have at our disposal, the antiretrovirals, they do work and if a patient is on these medications and undetectable; they cannot transmit the HIV, so that’s really exciting.
Melanie: And Paul, last word to you on World AIDS Day. Let the listeners know what you would like them to know about this very important awareness day.
Paul: So, World AIDS Day started in 1998 and it is really a reminder to everybody, to people, to government that this illness has not gone away, that it is still here, that we still need to do a lot of work. There still needs to be a lot more research, a lot more funding and really World AIDS Day also helps raise awareness of HIV epidemic that shows support for people living with HIV and it also commemorates those who have died of HIV. And here at Boston Medical Center, we are celebrating World AIDS Day on Wednesday, December 6th from 10-12:45 p.m. with a celebration. We will have many of our community vendors. We will be honoring Dr. Alfred DeMaria who will be our keynote speaker as well for the event. Dr. Pierre will also be a keynote speaker and so we want to just invite as many people to come as possible to help us celebrate our successes as well as the work that we still need to continue to do.
Melanie: Thank you both of you for being with us today. And thank you so much for all your hard work. This is Boston Med Talks with Boston Medical Center. For more information you can go to www.bmc.org. That’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.