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HIV Care and Management: Closing the Gap on the Epidemic

December 19, 2019


>>>Good morning and welcome to 3A: HIV Care
and Management: Closing the Gap on the Epidemic .
>>This session is being recorded. The views, opinions, and content expressed
in this presentation and discussion do not necessarily reflect the views, opinions, or
policies at the center for mental health services, the Center for substance abuse treatment,
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We do invite you to tweet about this session using. Please put any questions in the all questions
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because it is hard for us to keep track. I want to make sure everyone has sound. If you look right about this slide to the
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hand for me. Thank you. With fact, I will pass things over to today’s
moderator. Can you verify you are off mute?>>Thank you, everyone for coming to day 2
of our conference. It has been a great conference so far. Hopefully you have had a chance to be in other
sessions yesterday. Today we are talking about HIV care and Management:
Closing the Gap on the epidemic. We have Dr. Veronica Jenkins with us today. Without further ado, we will pass it to Dr.
Jenkins and have a productive and informative session.>>Thank you, very much. Welcome to all of the participants. I have been charged today with talking to
you about care and management of HIV. I will try to move the slides along in a very
professional way. Thank goodness they have technical assistance
to help me. These are the goals for this particular session. I want to review the epidemiology and some
of the infectious disease trends. We will discuss this — strategy and need
for prEP. We will review guidelines for treatment initiation
and then a few slides for virally suppressed persons.>>I think all of us who have been in this
field for a long time have a tendency to become very philosophical. Essentially, what I’d like to convey to you
is that with this disease, HIV, we have to be diligent in almost every session that we
come in contact with potential clients>>I would like to give my disclosures. I forget to do that because I have none. I am not a researcher, I’m just a clinician. Please believe me when they say the only person
responsible for the content of this session is me. That comes from 25 years of working with HIV
clients in Washington, DC. Let’s talk about the epidemic. I think most of you are aware of who is affected
and where. I want to review that with you quickly. If you look at this particular slide, the
most compelling thing is at the very bottom. Since the beginning of the pandemic, 78 million
people have contracted HIV. Of those, 35 million have died of HIV and
AIDS related illnesses. I think that the sciences are starting to
catch up and defray some of these numbers as you will see toward the end of this lecture.>>More of the epidemic. A lot of subpopulations have been identified. If you look at this particular slide you will
see that these are according to sexual contact. Black MSM have the highest number of HIV prevalence
of all of those that have been identified including white MSM, Hispanic MSM, black women
Hispanic and white women. What I want you to take away from this, not
necessarily what you see on the slide, these groups are dynamic. Just because a person identifies with this
particular sub-population does not mean that they stay in that sub-population in real-life. There are some in the male to male contact
group that moved back and forth between heterosexual acts as well as male to male contacts. If you go to the next slide, we are looking
at another picture about a transmission by category. You will see that 67% of the new infections
come between male to male contacts but when you add in other high risk behaviors we are
talking 70% of the new infections. That is a number we need to keep in mind,
bear in mind every time we see someone in the clinic and were trying to develop a treatment
plan for them. In 2015, I think if you look at the last bullet
point, it says gay and bisexual men accounted for 55% of people who received an AIDS diagnosis. Of those men, 39% were African-American, 31%
were white and 24% were Hispanic or Latino. I think these numbers are very compelling. They really urge us to be more diligent when
we are seeing men in our practices, whether from a medical standpoint, case management
standpoint, psychology or when they are coming in for treatment of substance abuse. We must absolutely start to ask our clients
about their sexual history and their risk for high risk behavior.>>Another picture to look at these new diagnosis
by race and ethnicity. You will see one of the highest groups affected
by the African-American population. That is followed by white and then Hispanics. We have not really discerned what the underlying
factors are. It can be a multitude of things. This can be lower social economic problems,
education, lack of housing, homelessness. All of those things play a part. That is high risk behavior including what
most of us recognize is substance abuse. Is it the only thing? No. I think it is a combination of those things,
and we have to be very sensitive to those when we are treating and try to treat our
patients in the future.>>I did want to share with you what has happened
with us locally. Washington DC was in the news quite a bit
in terms of our high rate of HIV infection. On this particular slide, in 2009 our rate
of infection was a 3% of the population. That is so much higher than the general population
of the nation. We try to do some things to make a change
in that regard. In 2015, we were going through the numbers
and found that indeed we dropped from 3% to 2.5%. Even though that does not sound like a lot,
it made an immense difference in the number of people we probably prevented transmission
for. The kind of things that we did which I know
a lot of you have done, or early testing, we got out there with mini vans, mobile vans,
signs on buses there were pamphlets being distributed, we were alerting people the disease
was there. You would be surprised when you sit down with
your clients that some of them will actually tell you they do not know that much about
HIV. They do not know anyone who has the disease. I thought the first time I heard that after
maybe the first 20 years, that had to be a mistake. You will find that people really do not have
an idea about what HIV is all about. The second thing that we did was increase
monies and funding to make needle exchange, something routine for our clients. It says we decreased the IV drug use. I wish. We did not do that. We did do was make the transmission of HIV
much less by having folks use clean work. We have to talk to our lawmakers in our healthcare
providers or the people who are in charge of helping us to get rid of this or to decrease
the transmission of this disease by making needle work available. We need to educate the HIV user. Go to where they are. We took our mobile band to the most popular
places, and we made sure they could put their dirty works in a container for them to be
destroyed and give them clean work. I think it made a significant impact on the
transmission of disease by IV drug use.>>One of the other things we did was the
red-carpet treatment. Several of you, I have noticed in doing a
bit of research are doing something similar. Red carpet simply means that once we made
a diagnosis in the field, we immediately moved that person into the medical intervention
setting. Anything from getting into see a provider
to at least getting them into see a case manager so we could start the foundation for getting
them treated. I think it has made quite an impact on getting
folks into treatment when we are trying to get this disease under control. Once we do all of those things to educate
people, what do we do in the continuum to simply prevent HIV negative people from becoming
infected? I think there are several things we can do. These are three of the big steps. We have to talk about abstinence. We have to keep talking about abstinence. I can see some of you shaking your head and
saying, we talked abstinence but our folks are doing a lot of things and having sex for
money and all of those things. I think that abstinence may be something we
can talk about particularly for our young people. I think it may not have worked as well as
we like to think it did but we have an involved all of the players in the game. That means involving not only the client but
the church, the parents, the school. We’ve got to talk about sexually transmitted
diseases and the possibility of HIV infection. Abstinence is still there. I think that barrier methods, I have to admit
that I do not always hear as much about the barrier methods and the use of condoms as
I used to in the beginning of the epidemic. I have gone to some area clinics and failed
to see the baskets of condoms that we used to put out. We used to buy them by the gross so people
could easily walk in and get back. The condoms to take out with them. I do not want us to throw the baby out with
the bathwater. If you were not talking about condoms, please
start. There are also studies for vaginal barriers
for women to use. I think we are out with all of the data. It works, but it is important that the women
who use these vaginal barriers adhere to it each and every time. I don’t know how many of you are that familiar
with the female condoms. They can be as not easy to use. So do not throw that out either. I think it is a viable alternative, so condoms,
let’s put them out there and then let’s also talk about vaginal barriers as well. You will find that there is research out there
based on medications, gels for the Regina, but we need to get the word out — gels for
the vagina but we need to get the word out.>>And there is one last thing to make sure
the negative HIV person is protected and that is PrEP. The basis of this is simple. The idea is to get all of the high-risk negative
people, treat them with the medication to see if we can’t stop the foothold of the virus
in the bloodstream. There was a study done in Australia called
EPIC-NSW and it is the use of prEP in New South Wales communities in Australia. They got over 4000 high risk MSMs to take
PrEP. I think the results are astounding. Once they accounted for those who did not
take the drug properly or did not adhere as they should, there was a significant, more
than 30% drop, in the rate of infection for those who took PrEP. Some of you are saying, okay, let’s talk about
PrEP and what does it mean. PrEP is the use of a medication to be taken
by the HIV negative person on a daily basis to prevent the spread or the transmission
of HIV through high risk behavior. We have found that daily PrEP use can reduce
the risk of getting HIV from sex by more than 90%. That is an astounding number. Daily PrEP use can also reduce the risk of
getting HIV for people who do injection drugs by more than 70%. I go back to my first slide in we do not necessarily
reduce the use of IV drugs. We reduce the transmission of the disease
for those who do in drugs. If you are still wondering what PrEP means,
let’s look back. It stands for pre-exposure prophylactics. It is the care we give to the HIV negative
person in order to prevent them from getting the disease through whatever mode of transmission
they are using, whether sex or IV drug use. If you look in the corner you will see that
little blue pill. Not the other blue pill, but this blue pill. It is Truvada. I will step away for a minute to say this
has become common that our clients know the names of their medicines. As a former teacher, I made sure that they
know the names of the medicines every time they come in. We use the brand names a lot. I know sometimes it will be a little confusing. We use the generic and chemical names. Stick with the brand names if that is easier. The currently approved combination is Truvada. It is only available with a prescription. It does have some side effects like headaches,
nausea, and vomiting. One of the things we have to be most prepared
for is, of course, the problem with Truvada and causing some mild kidney dysfunction. There are guidelines about using Truvada for
anyone rather for PrEP for the treatment of HIV. And of course, cautious use for anyone with
osteopenia and osteoporosis.>>So how do we move from PrEP to treatment? PrEP was for the clients who are negative. And now we are going to talk about what happens
when you get the person who is HIV-positive. Someone who gets tested in the mobile band
or outreach or even in the clinic. So now they are positive, and what do you
do? Once you have determined that they are negative,
I’m sorry, that they are positive, make sure you have elicited a good history and you know
about all their high risk behaviors and the things that you can do to make things better. I put here in this like, let’s get your history. Use nonthreatening type of questions. Once a person learns they are positive, everything
else goes out of their mind. I do not care where you deliver the news,
it is always devastating and puts a new burden on their shoulders. So take the history into the right things
when you are trying to get their history when moving forward with treatment.>>When you are doing the test to find out
whether they are positive, most of you are familiar with mouth swabs the test for the
antibodies and also rapid blood testing for viral antibodies. When they are in the medical setting, fourth-generation
viral testing to get the viral load. I have here on the slide that you can detect
the virus with the fourth-generation testing kits in about 28 days. I believe the window is closer to 14. They are faster and more accurate and they
can supplement whatever you do in the field. If you are doing antibody testing in the field,
the fourth-generation does testing for components of the virus. Now that you have confirmed that they are
indeed positive, it is time to move to treatment. Before we talk about treatment, I want to
tell you there are testing guidelines. Everyone should be tested at least once between
the ages of 13 and 64. Let me just give you this one caveat. Remember that people have sex, or assaulted,
or use drugs and they can be younger than 13 and older than 64. It is incumbent upon you to remember that
HIV is a possible diagnosis no matter where you are in this continuum.>>So now we have definitively gotten the
diagnosis. We have an HIV positive person and we have
decided that they need to come into the medical setting and we need to move forward. Went do you start therapy? I think the basic guidelines now tell us one
thing. When you find out they are positive, once
you are absolutely certain that they are ready, you need to start treatment as soon as possible. There are lots of studies out there and this
particular slide talks about accumulative group of studies that suggest the strategic
time for starting treatment. And what the summary of all of them have given
us is that the ideal time is the start as soon as you find the diagnosis. What does that do? When you start treatment almost immediately,
what you do is decrease the incidence of HIV or AIDS related co-morbidities. This has been proven over and over again. I will tell you from this slide, our colleagues
in San Francisco did a study called the RAPID study to solidify this type of information. They did the testing, had the clients get
into medical treatment within five working days, and as a result, showed just that. People had their virus suppressed in 50% of
the time it used to be. It would take us upwards of three months potentially. With rapid onset of treatment after the initial
diagnosis, virus suppression came as little as 60 days after they started their medicine. Based on the fact that they were adherent
and doing everything they were supposed to. I think all of the studies tell us that once
you make the diagnosis, it is time to start talking treatment.>>I think one of the most important things
we can do is to treat our clients as individuals. I think one of the things that the panel tells
us to do is to do just that. Treat each person on a case-by-case basis. If a person comes into you after having gotten
a positive test result and they say, do whatever you do to make me healthy and keep me healthy. Well, then do that. You can start treatment on that day. Inevitably, you will get a person who was
so overwhelmed by this infection or the presence of this infection in their health that they
are not ready that week. They may not even be ready that month. I say to you when it talks about being really
ready to start, know that you should use a case-by-case basis meaning that therapy can
be deferred because of clinical and psychosocial factors.>>Let’s just say this, ask yourself these
questions when you’re trying to decide when to start. First, the middle bullet. Is the client ready? Do they have a support system? One of the things I found out during the course
of my treatment of folks with HIV, a lot of them gave up quickly once they got the diagnosis. As a result, a lot of them said, all right,
let me just end everything. They gave up everything. They maxed out their credit cards, moved out
of their homes, lost their jobs. They did not think there is anything worthy
to do after that. So that is when I started a transitional home
for people to use stable housing as a means to stay it here into their medicine. So for sure they have to be ready mentally
and physically in order to start this treatment.>>This is a list of things I think the provider
should be guided by when they are trying to choose the right regiment. It looks a little overbearing talking about
a virologic efficacy and whether or not the medicine were work or whether it will be killed
by the virus. This is what one does when ever you are trying
to do any disease, not just HIV. Do not be overwhelmed by this list of things
you should consider. You do this each and every day. Whether you are prescribing methadone, diabetes
medication, hypertensive medication, it is still the same.>>So now we talk about treatment. We have gotten to the part about support and
we have made the diagnosis. Let’s talk about treatment. Historically we have been taught that the
best way to treat anybody was to include two classes of one type of drug. Here other classes. Nucleoside reverse transcriptase inhibitor,
Non-nucleoside reverse transcriptase, Protease inhibitors, fusion inhibitors, CCR5 antagonist,
integrase strand transfer inhibitors. It sounds like a mouthful. Why is this important to know the classes
it is important to know for several reasons. If you know the lifecycle of the viruses it
goes like this. The virus attaches to the T cells and then
if anchors itself with two other receptor sites. It fuses into the cell and changes from is
no more single-stranded genetic material to double-stranded DNA. It integrates into the mechanism and replicates
itself and then breaks free to go on to make new little baby viruses to infect somebody
else. Each of these classes of virus effects that
lifecycle at one of these points. Historically, what the scientists have gotten
us to understand again is that in order to best eradicate this virus, we need to use
two drugs from the nucleoside reverse transcriptase inhibitor class and then went drug or base
drug for anyone of the other class. I will tell you that preferentially we use
two nukes plus a non-nuke or a protease inhibitor or now integrase strand transfer inhibitor. That is not to say we don’t use fusion or
CCR5 antagonist but they are falling a little bit out of favor and that is why I only listed
those.>>I will show you this drug list. Please do not be daunted by a. Not at all. There are 40 pills on this chart. You do not have to learn 40 pills. You will learn them, but you do not have to
learn them all at once. I think that our guiding panel of folks who
are the talking heads who probably know a lot more than me, they have decided to make
this as easy as possible for us based on the experience we have had in treating HIV. You see on the slide the panel guidelines
for adults and adolescents has four choices. This particular slide, I think I looped the
first choice up in the top half. The first choice is Dolutegravir, Abacavir,
and Lamuvidine and for those knowledgeable, that talks about Tivicay plus Truvada, a two
pill regimen. Of course, you have to understand we are trying
to push towards the single tablets and the once a day regiments. Not all of them are just single pills. So again, Tivicay plus Truvada. The very first choice is Dolutegravir, Abacavir,
and Lamuvidine which is Triumeq. The second choice is Dolutegravir, Tenofovir,
Emtricitabine is Tivicay plus Truvada. The third choice is Elvitegravir, Cobicistat,
not a new drug it is actually a booster Tenofovir and Stribild. And the last, Raltegravir plus Tenofovir and
Emtricitabine, we know as either Isentress plus Truvada or in some cases we know these
as Truvada .>>Why is this like probably the most important? Because of the 40 pairs that were on the previous
slide, the guidelines tell us let’s consider this four regimen pill treatment for our clients. That knocks it down significantly.>>Before I start with this new slide, in
the last year they have come out with a new drug. I suspect that over the course of the years
we will see new drugs all of the time. You will have time to assimilate each of these
new ones along with the old ones. If I can just go back to this old slide, you
have these four choices. This covers almost everyone. Choosing the right regimen should be fairly
easy. Four choices. Either two pills are a single pill a day. I can tell you across the board this will
work. Just to add to the armament, the newest drug
n the regimens to be chosen is Biktarvy. A single tablet regimen one today. It does have its caveats and I’m not going
to go over this. You can read this at your leisure to know
when to use it and when not to use it and what might be the problems with the drug interactions
and that kind of thing. It is not on the 40 pill chart. When they update the chart, this will probably
be pill number 41 or 42. Again there’s a new
regimen called Juluca. Historically we have said to use two nukes
and one base drug. This is actually only two pills and not three. HIV treatment is an ever-evolving disease
or the treatment region is ever evolving. You have to stay on your toes with that. Just remember that when you’re looking at
your poster of tablets. You’ve got four primary choices.>>Here is what I want you to also remember
when you are starting to treat someone with HIV. You probably should do a set of initial labs. You will do the CD4 count that checks their
immune status and how strong or weak it is and how progress the disease is. You will check the viral load and you will
check for something called the HLA5 701. One of the regimens you use a drug called
Abacavir and it has a propensity to cause severe allergic reactions. There is a marker in the blood to let us know
when that might happen that is the HLA 5701. With all new initiatives, I would say the
initial should include these basic three. CD4, viral load, HLA 5701. You do the other things like checked her kidney
function, liver function, hemoglobin, hematocrits because you want to be thorough. That will help you to make a decision about
which medication to start out of the four that have been recommended. And then every quarter you’re going to be
doing the standard maintenance kinds of bloodwork. This is just to see their viral load and to
see how well it’s working and to check the liver functions. Most of these drugs are metabolized in the
liver. Sometimes it can be overwhelming and overtaxing
if they are taking multiple drugs particularly the drugs that help them with substance abuse
like methadone which are metabolized in the liver as well. They can cause differences in medication concentrations
in the blood. Of course, once you have started treatment,
make sure you were doing the preventatives. Menopausal women are women who have symptoms
of menopause, it is important to do bone density studies. We don’t always consider them for men, but
I think we should. Remember that the one drug we use as one of
the components of the prEP medication does cause problems with bone density. For people effected with new infections start
using PrEP, their bones need to be checked too . All of the other preventive things. We must be vigilant for all of these things
like potential cancers and everything else because folks whose immune systems have been
compromised have a tendency to have a higher incidence of cancers than the general population. So all of the preventive things.>>I need not to go over the slide for any
length of time but to say these are the things you have in your armament. Smoking cessation, stop drinking, control
high blood pressure, make sure their sugars are under control and weight, exercise, and
diet. I was going to spend a little bit of time
talking about a case for you but if you read this, you will know what to do. One thing I will say about this and about
all of the people you will treat is to make sure that when they come in for treatment
or even testing, you are getting an excellent drug use history and that you are also talking
about the other high-risk behaviors. Make it a part of the combination so that
there are no stones unturned. So you can choose the right regimen.>>I will say this too, there is no such thing
as a classic presentation of HIV or a person who was a substance abuser. You know very well they will come in and be
the most stoic of all the clients that you see. So no such thing as a classic presentation. There is no reason to not get a history for
all of the clients you see. All the studies say therapies should be started
regardless of their CD4 count. Make sure the client is ready in order to
help them be better served by the medications and the service that you give them. And one less thing we haven’t talked about
is resistance. What is that? Sometimes in areas where the prevalence of
the disease is very high, somebody may be infected by a virus that has already been
exposed to medicine. As such, if you just go in and decide to treat
on that first day without having the results of the test, you may be trained to treat a
virus that has already seen the medicine that you are proposing to use. So here we are. You can do a resistance test. It will let you know what medicines will actually
work for this particular strain of the virus. The lab that we use is Labcorp. The test will tell us the physical ramifications
of the medicine. If you have a virus and put it in a jar and
put the medicine in and come back the next morning and there is a tree growing, you will
know that that medicine does not work. If you put the virus in a jar and come back
the next day, and the jar is clear you know that the medicine works. If you do this type of testing through Labcorp,
the resistance test will list the medicine and give you a good hint about what will work. The medicines around the left hand side and
the results are on the right-hand side. If indeed the medicine works, it will be blue. If it does not work, it will be black. Genotypes talked about the genetic markers
that tell you whether or not this medicine will work. If it’s going to work, it is blue. If it is not going to work, it will be black. That is your quick resistance test. The stuff in the middle tells you about the
genetic markers and whether the virus is replicating easily. As a clinician, I don’t pay much attention
to that. I go straight to the black and the blue bars.>>So here is my baseline. The key to successful treatment is this: adherence,
adherence, and I know you’re saying it with me, adherence. The one thing you have to do is you have to
involve the full staff. If the person is a substance abuser, you must
work with the substance abuse counselor. If they need housing or employment you have
to work with the case manager and the employment specialist. If they have mental health as a barrier to
their care, you must work with the psychologist. If they are on an armament of medicine, you
have to work with the pharmacy. I know that most of us are pressed for time
trying to get clients in there so we can keep the clinic working. In order to get the best results for our clients,
we have to use adherence by working with everyone.>>I’m going to skip this slide. I know that you will incorporate all of those
things. And then one last word. When we are trying to talk about simplification,
we want to make it easy for our clients to take their medicine and be adherent. I was going to spend a little bit of time
with this but when a person has been adherent and taking their medicine every day, if they
decide that they are on a three pill are two tell regimen and want to go to one, you can
simplify. As long as the patient will be adherent you
can switch to a simpler regiment. You can start them on a simple regimen and
if that does not get it and they work hard with the medicine they are on and they have
been suppressed for three to six months or better, you can go to a single tablet once
a day.>>I am going to skip this slide and move
to the ends. I understand we have some questions. I want to review with you a little bit about
the special considerations. Know that you must check kidney function. A lot of them do have that as a side effect. There are some drug interactions. There are common things like bone density
that might make you choose a separate regimen or a different regimen than the one that is
recommended.>>Last but not least, just one tiny slide
about hepatitis. First of all, know the people was hepatitis
whether chemical or not, virally induced, there is no reason you cannot treat both illnesses
while treating HIV. No reason whatsoever. If they are taking medicines to treat their
substance abuse, there is no reason why they cannot be treated. And injection drug user can also be treated
for HIV and hepatitis. It takes a lot of thinking and you have to
do a lot of drug interaction research. It is not impossible. A little slide just to give you a guideline
when you are talking about Hep C and HIV treatment. You can review that at your leisure. It makes the choice of medications very simple. It means working with the client to get the
very best results. Unfortunately, we know that there has not
been a decrease in injection drug use in the United States. Here in DC, we seem to be having an increased
number of IV drug use. It doesn’t mean we cannot treat these people. We do have some drug modifications you have
to do. The bottom line is this, therapy depends on
the patient, the clinician, the clinician’s patience, their medication knowledge, and
of course our watchful determination. It is a chronic disease but not difficult
to handle. We may not be able to cure, but we can put
it in remission. Get together with your staff and do this. Use your web resources. I think Google is wonderful. I am learning not to believe everything Google
says, but it is there.>>With that I will stop. Thank you for being a captive audience. If you have questions, I am willing to take
them at this time. If not, you are free to email me. We can answer any questions later. Thank you very much about spending this hour
with me. I appreciate the honor you have given me. Hopefully I have been helpful.>>Thank you so much, Dr. Jenkins. We’ve gotten a lot of feedback and people
are really enjoying your straightforward approach in making the topic digestible for people
of all backgrounds. We do have a couple of questions. The first one is from Colby. Do you think the higher rate of newly diagnosed
HIV infections is also due the accessibility for testing? Are more people getting tested because of
access especially those in minority MSM populations .
>>Great question. I was seeing more positives because we are
out there testing? I think the answer is definitely yes. Even as clinicians we hid behind our clinic
doors for a while. Even we did not understand it all. Now that we do, we know that it is a manageable
disease, we have gotten out there. Our health departments and lawmakers have
decided to test everyone and turn the tide on this disease. We can do that with early testing. Yes.>>There is a follow up or another question. If a client is able to start treatment but
is resistant, how effective will starting treatment be without resistance?>>Without resistance?>>With that resistance.>>I think this question is leaning to what
happens if you find that the patient does have some resistance to medication? Over my span of 25 years, I have come across
quite a few clients who were indeed resistant to some of the standard medicines we were
using early in the course of the epidemic. The newer drugs do seem to work. Remember, we have gotten at least two new
drugs over the past two years. I think, particularly using drugs like the
protease inhibitors, there is a chance that folks will have, I don’t want to say a mutational
change, but definitely some of the drugs you can go back to and use again. I have used those drugs some folks that have
had mass resistance meaning the whole column was black. They have to be consistent with taking the
drugs. They have gotten better. Is it the end all of and all’s? I know that I did not have anyone to get AIDS-related
illnesses even though they still had consistent persistent [indiscernible]. There is no great answer for that except to
do the best you can with what you’ve got.>>Sure. That makes a lot of sense. A couple of people were wondering if you could
share more about the medical group home that you started. People are interested in that concept. Maybe you can give more detail about that.>>Let me just say, like I said, I started
treating HIV back in the late 80s, early 90s. A lot of the patients at that time truly did
kind of give up. We did not have a good and positive future
for them. We kept saying things like you’ve got 18 months,
24 months, we will do the best we can. People simply gave up. What I have found is that I had to start being
more of the uplifter and say, listen, you are not going to die from this disease if
we work with it carefully. One of the things I have found is that most
of them became homeless. As a result, I decided that one of the components
of adherence would be stable housing. My husband and I got together and bought a
building and started opening up apartments for homeless people who were positive. That grew to become Homes for Hope. For 16 years now we have been doing that. The idea is to get them in, revitalize them,
get them stable housing, teach them a trade and let them understand that there is life
after HIV. That is not the end-all of end alls. I must say, I think we have been so very successful. We have a 78- 85% rate of independent housing. We did not fix everybody. We did the best we could.>>If you compare that to other housing programs,
that number is really good outcome for transition folks.>>We got another question here. Is there any known concerns about individuals
on HIV medication and taking medication -assisted treatment like methadone? I may be butchering the pronunciation.>>So is there a problem with combining all
of these medicines? HIV medications with substance abuse medications,
and the only problem is identifying the drug/drug interaction. Some drugs like methadone, you may have to
increase in order to prevent withdrawals. Some HIV medicines you may have to change
from one class to another. I think the bottom line is this, there is
no reason, absolutely no reason, unless there is something physically wrong or another condition
that could impart some problems, there is no reason not to treat injection drug users,
people with hepatitis, those with HIV all together or in combination. It takes a little bit of research. You’ve got to sit down with your pharmacist
and talk about the drug/drug interactions. I have done it, and done it successfully. You can too.>>Thank you. That is very helpful. We are bumping up on our time. If anyone has any last minute questions, we
have gotten a lot of positive feedback in the public chat. I really want to thank you, Dr. Jenkins. You have made this topic approachable to people
with all kinds of backgrounds. We have quite a mixed audience here. That is really good. Do you have any final thoughts? We have your contact information up there. Folks can jot down your email it they have
additional questions or if they want you to come and speak for them. You are a great presenter. Are there any more thoughts before we move
to our exit survey?>>If you want to come to DC, come by and
see me. Thank you so much.>>Thank you. It has been very well received in an awesome
presentation.>>Will you move us into the exit surveys?>>Yes. Right now on your screen you will see a couple
of exit polls pop-up. We would love to hear your feedback from today’s
session. If you look at the top left of your screen
you will see the link to the next session available. If you want to copy that down are you can
click on it and access the early log in that would be great. Thank you for joining and we look forward
to seeing you in the next session.>>[ Event Concluded]

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