By: Al Ballesteros
The first cases of AIDS were reported on June 5, 1981 in California. Nearly 40 years later, about 750,000 persons have died of AIDS and about 1.2 million people are currently living with HIV disease in the United States. It is believed about 1 in 7 or 15% of all persons infected with the virus in the US do not know their status (CDC).
An initiative called “Ending the HIV Epidemic” was started by the Trump administration in 2018 with the goal of cutting HIV infections by 75% in five years and 90% in ten years or by 2030. In order to participate and receive funding from the federal government through this initiative metropolitan areas like Los Angeles Count have to submit a plan of action on how it plans to use funding to reduce infections and control the disease.
We are on our way into this new national initiative with an exciting name but I’m still pondering what it will actually take to end the HIV epidemic in the United States or here in Los Angeles County. It is for sure a great national goal and activists will say this conversation is long over-due. There are hard realities with which we have to grapple as we attempt to help those who are challenged to retain in care and help other high-risk groups prevent themselves from becoming infected with the virus. Diagnosing and testing more people will not in and of itself, lead us out of this epidemic.
In Los Angeles County, estimates are that 58,000 persons are living with HIV. Cisgender men comprise 87% of new diagnoses and women 11% with transgender persons comprising 2%. Men are getting infected through male to male sex representing about 90% of their infections. About 4% of men were infected through male to male sex coupled with injection drug use at 4%. For women, the primary mode of transmission was having sex with a male at 75% and injection drug use at 25%.
In Los Angeles County, at the end of 2017 it was estimated approximately 6,400 persons or 11% of all those infected were unaware of their HIV infection. The largest group of persons unaware of their HIV positive status is thought to be young people between the ages of 13-24 and 25-34. From an ethnicity standpoint, African Americans and Latinx people are the groups most highly impacted in recent years and comprise the majority of recent infections. Transgender women are believed to have the highest incidence rates given their population size. When individuals are unaware of their HIV positive status, it is more likely that the infection will be spread to other individuals.
The national End the HIV Epidemic guidance is focused on four pillars which are required for each plan: Diagnose people as early as possible; Treat people rapidly and effectively, Prevent new HIV transmissions, and Respond quickly to HIV outbreaks (CDC.gov, Ending the HIV Epidemic).
Almost all would agree that significant investments to diagnoses, treat and prevent will bring down the spread of HIV disease. More funding from Washington placed towards these goals will help make up a deficit that has existed for years for these services as there has never been enough funding. But can the investments in these areas make a significant difference given that HIV is affecting the most marginalized groups, who have traditionally had poor access to health and social services in general. For many of these “hard to reach” populations, their HIV treatment and prevention needs often falls lower on the list of priorities and/or they are hindered by circumstances and or other individual challenges.
These community factors and social determinants of health need to be addressed because diagnoses, treatment and prevention alone do not happen in a vacuum. Issues such as racism, homophobia, transphobia, poverty, substance use, mental illness and homelessness, just to name a few have to be considered if we are to make a real impact towards ending the HIV epidemic nationally and here in Los Angeles County.
Richard Zaldivar, Executive Director of The Wall-Las Memorias says “sometimes the plans don’t line up…policies are often created at the national level and the state and local levels have to follow the mandates to address HIV. It is good that the federal government is addressing HIV to this magnitude. But the plan really lacks a sense of depth to the communities which are impacted most,” says Zaldivar.
“We have to address the issues of immigration, workforce, housing, homophobia, bigotry and transphobia. You can’t expect transgender and gay people to go into offices for services and testing if they are getting beat up while on Metro-Lines going there. Or when they are thrown out of their housing and are forced to live under bridges and fight for their daily survival,” says Zaldivar.
Zaldivar points to substance abuse and the ongoing Crystal Meth epidemic as a main driver that is contributing to HIV transmissions and to individuals falling out of care or not being retained in care. He does not believe there are enough programs operating to help Latinx people using Crystal Meth who are at risk of HIV infection, especially programs that are LGBTQ friendly.
Why the lack of programs? “Maybe it’s the nuance of meth and the stigma that it carries. There are not many successful programs that deal with Meth because Meth is a difficult addiction to address. Just like anything else, we have to draw attention to the problem. Funding is needed from public health and from researchers to develop effective programs for meth treatment. The only way to do this is to have the community talk about it. Here we are months away from vaccines for Covid-19, and it’s critical we do have these and I understand that. But where are we with treating Crystal Meth?,” asks Zaldivar.
To address this Crystal Meth crisis The Wall-Las Memorias is launching the “Act Now against Meth Campaign” to call attention to the epidemic and it as a driver of increased HIV infections.
“No one is really talking about Crystal Meth at the Federal Level. This is a huge problem because we can’t really address this problem unless folks at the institutional levels believe it’s a problem.”
Public health experts, HIV advocates and many affected believe there is a correlation between meth use and the incidence of HIV and STDs but that correlation has not been properly studied and therefore, it is difficult to quantify. The Act Now against Meth group is asking Los Angeles County to prioritize the treatment of Crystal Meth and to view it as a contributor to HIV and STD infections just as alcohol was once identified as such and almost certainly still is.
Adelante: Where should our community begin to prevent meth use and have the conversations about its correlation with HIV infection?
Zaldivar: “It should be talked about in school and community-wide. We really need to talk about the nature of addiction and how that works within our families and cultures. We also can’t isolate meth and not talk about alcohol. We’ve seen such a large amount of alcohol establishments open up in Los Angeles and in people of color communities. This is especially problematic in that we have a lot more alcohol establishments than in non-people of color communities. We need more conversations about addiction, substances and the type of harm these substances cause, including placing one at increased risk of acquiring HIV infection.”
Treatment for active HIV infection is critical for persons with the disease to live normal lives and also to end the HIV epidemic. Treatment with antiviral drugs helps the person with HIV remain healthy as the drugs bring the person’s viral load (the amount of HIV in the blood) to very low levels or undetectable which prevents the infection from being transmitted to another individual. But remaining in care and taking one’s medications without fail is very difficult for some subpopulations living with HIV disease given the many challenges in their lives.
Harold Glenn San Agustin, MD with JWCH points to three social determinants of health which he believes impacts retention in care and adherence: Housing status, substance use disorder and unaddressed mental health issues. “Housing is fundamental and I can’t emphasize this enough.”
Housing status impacts the person’s ability to properly care for one’s self as a home is a place to rest in from the elements and also somewhere to store one’s medications which are frequently stolen on the streets from homeless persons. Dr. San Agustin points to needed programs such as HOPWA and emergency housing options for patients he treats. Long term permanent housing should be the ultimate goal. “I can’t tell you how many times I hear I lost my medications or someone stole them. This affects their adherence,” says Dr. San Agustin.
Dr. San Agustin also says substance use is a huge barrier to adherence and retention in care and believers increased access to culturally affirming programs are needed in order to End the HIV Epidemic.
Dr. San Agustin says it is just as important to ensure that mental health issues are addressed because these also affect retention in care and adherence. This calls for timely access to services for mild, moderate and those with severe mental illness who are living with HIV or at risk of acquiring HIV disease. “When patients are having mental health challenges or they are spiraling or in a manic or delusional state, they often are not taking their medications,” says Dr. San Agustin. It would be important that these populations have access to long-acting injectable psych drugs for chronic mental health conditions coupled with their HIV treatment and/or prevention needs.
Poverty itself gets in the way of retention to care and compliance to medication regimens because the person and communities are struggling to keep up with basic necessities of life such as keeping a roof over one’s head and meeting food needs.
The importance of access to a cell phone and accessibility to communicate with one’s doctor, case manager, peer advocate or social worker is also critical. Dr. San Agustin believes a “common thread” seen in his patients who do better in retention and compliance is they have good and regular communication with their doctor or counselor or advocate. So fostering effective communication between patients via cell phones or e-mail can make a big difference and should be considered in Ending the HIV Epidemic.
Competing priorities are also a challenge for populations living with or at risk for HIV. Often priorities such as looking for or maintaining a job, caring for one’s children, dealing with legal or immigration matters gets in the way of one’s health care needs.
As the objectives associated with Ending the HIV Epidemic rollout, one certainly hopes that conversations continue as to how to meet the various challenges and social determinates of health for these populations. We should explore enhanced substance abuse programs, housing, food access, mental health support and other enabling services and whether there are enough resources available to those at risk or living with HIV disease. These programs need to be fully integrated together for the person living with HIV and those at risk with their HIV treatment and support systems. All this needs to happen within the context of dealing with racism, homophobia and transphobia. This is a tall order for Los Angeles County and large metropolitan areas around the country dealing with this same issue.
Enhanced conversations and working relationships with the various county social and health programs, hospital systems, Medicaid Health Plans and other charitable foundations and organizations, just to name a few are needed to support these goals and critical if we are to move the needle forward.