Barriers to HIV Care and How a Fragmented Health Care System Impacts This Patient Population

Chris Beyrer, MD, infectious disease epidemiologist and professor at Johns Hopkins Bloomberg School of Public Health, discusses fundamental barriers within HIV care, and how the US health system can better manage the HIV epidemic, which includes addressing challenges linked with PrEP coverage. 

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network, where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today we are joined by Chris Beyrer, MD, infectious disease epidemiologist and professor at Johns Hopkins Bloomberg School of Public Health. He discusses fundamental barriers within HIV care, and how the US health system can better manage the HIV epidemic, which includes addressing challenges linked with PrEP coverage.

Dr Beyrer?

Surely. I am Chris Beyrer. I'm an infectious disease epidemiologist by training. I am the Desmond Tutu Professor in Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health.

I've worked on a range of infectious disease, but primarily HIV/AIDS, viral hepatitis, TB, and now, for the last year, I've been one of the members of the COVPN, the COVID Vaccine Prevention Network, and working on the COVID vaccine trials.

What are some fundamental barriers and challenges that need to be addressed within HIV care?

Well, there are a number. Certainly, one of the issues has been access. The big challenge there is the access issues not for the lowest-income Americans, many of whom quality for Medicaid, but really, that large swath of the population that's the working poor.

Younger workers, workers who work in job sectors that don't provide health insurance, or only provide minimum catastrophic coverage, that remains an issue. We are also, of course, very concerned about the persistence of stigma.

Stigma in health care settings, particularly in the South, remains an issue. It has multiple components. It's what social scientists call intersectional stigma. What that means is there's stigma and discrimination against people living with HIV, first and foremost.

Secondly, there is anti-Black racism, which is a very real issue in this country, as we all know. Thirdly, there is still a lot of homophobia. There is discrimination against LGBT people and trans people, who are the most-affected in this country, and who are the most likely to be mistreated in health care settings.

Actually, we're developing, my next big project, is going to include an intersectional stigma reduction program for health care workers in the South to try and improve outcomes for Black gay and bisexual men. We think that that's really important.

This hasn't been done so much in the HIV area, but there have been anti-stigma and anti-racism efforts and programs to deal with cancer disparities, which it turns out are also a function of discrimination in health care.

Does a fragmented health care system impact care for this patient population, and how can the US health system better address the HIV epidemic?

Yes, there's no question that the fragmentation of health care is a big problem. As I said, we see, particularly in the states that have not expanded Medicaid, a different pattern emerging, which is higher rates in rural populations.

That is very concerning, and it's really unique to the southeastern part of the country. It's challenging as well for a particular population who's very much at risk, which is adolescents and young adults. People start sexual life, on the average, about 15 or 16.

They're covered on their parents' health insurance. It's always challenging for adolescents to get sexual health services, and of course, we don't do that in schools, as so many industrialized countries do. Now, what we're seeing is that the highest rates of new infection are really in the 15 to 24-year-old sexual and gender minority youth, so gay, bi, and trans youth.

Those folks are markedly underserved in many health care settings. There are challenges with, for example, being on your parents' insurance if you might be a candidate for PreP, for pre-exposure prophylaxis for prevention.

That opens up a cascade of questions about why you're at risk and why you need this medication. Some families are supportive, and of course, others are not.

Overall, is there anything else you would like to add to this conversation?

I would say that what is frustrating is that we have a very powerful set of tools. The latest antiviral drugs, including the integrase strand inhibitors, dolutegravir, now coming online probably this year is going to be long-acting injectable cabotegravir for prevention.

Basically, a once-every-two-month injection could really be game-changing. We have tremendous advances in treatment and in prevention, but we're not getting them to the people who need them most. The unequal access and uptake in use of these technologies is really limiting our ability to control HIV.

We are not on a trajectory to get control of this epidemic in this country if we continue this rate that we're going at. We really need to ramp up prevention. We need to help people living with virus get virally suppressed and stay virally suppressed.

That's for their own health, but also to prevent onward transmission to sex partners. We need to get HIV back on the national agenda. That's going to be a challenge.

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