The first in a three-part series of conversations about an epidemic health centers have been on the front lines of addressing for decades: HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome). In this episode, HIV expert Nick Diamonds leads a conversation about new strategies for preventing HIV transmission.

Guests featured in this episode:

• Robyn Neblett Fanfair, MD, MPH, Acting Division Director, Division of HIV PreventionCenters for Disease Control and Prevention
• Juan Carlos Loubriel, Director of Community Health and WellnessWhitman-Walker Health
• Craig Thompson, CEO, AIDS Project Los Angeles (APLA) Health

Moderator: Nick Diamond, Manager, Editorial Services, Elizabeth Glazer Pediatric AIDS Foundation

Episode transcript


Episode transcript
Nick Diamond: I want to start with Robyn by asking you, "What excites you the most about the new evidence based-strategies introduced for people who are HIV negative and want to stay that way?"
Dr. Robyn Neblett Fanfair: Thanks to a robust toolbox that includes pre-exposure prophylaxis, post-exposure prophylaxis, treatment as prevention, and syringe service programs, we now have more tools than ever available for HIV prevention, and we must realize the full potential of these tools, we understand how important it is to make sure that it gets into the hands of everyone who needs them. So what excites me a lot right now is a status neutral approach to HIV prevention, which we believe can really help improve access, reduce stigma, and help prioritize health equity. So as far as exciting strategies go, it's really about reframing how we think about traditional HIV service models to better reach people where they are with the services that they need. So no matter their HIV status, we know that people need similar health care as well as essential support services. These can include medical care, housing, transportation, and employment. A status neutral approach can create a one door approach for HIV prevention and treatment, which can help normalize both. It eliminates HIV stigma by integrating prevention and care instead of supporting separate systems. And we believe it can enable people to know their status by making HIV testing and next approaches, whether they're behavioral or biomedical prevention, more accessible, and it can advance health equity by connecting people to the services they need regardless of their HIV status. So those are just a few things that I think are really exciting in HIV prevention right now.
Nick Diamond: And Juan Carlos, I want to turn it over to you to ask about your experience and programs at Whitman-Walker. Would you talk a little bit about what your health center is doing to improve HIV prevention services in the community? I know Robyn just talked about this toolkit; are you seeing the implementation of things in those toolkits at the health center?
Juan Carlos Loubriel: Yes, indeed. We are very excited about this new approach. Whitman-Walker Health delivers tailored education and sexual health services that are sex-positive and inclusive. Our training and linkage efforts are community-based service delivery interventions. They promote access to effective tools for HIV prevention and timely diagnosis. We also provide immediate access to nPEP (non-occupational post exposure prophylaxis) and PrEP (post exposure prophylaxis) for HIV prevention. We provide early diagnosis and prompt linkage to medical care, including ART (antiretroviral therapy). And these efforts occurred alongside treatment of HIV and other chronic diseases. We strive to eliminate barriers to care. And to do this, we deliver status neutral services and connect clients to medical, behavioral health, harm reduction, and social services through customized risk reduction. Staff provide health literacy and education for clients on understanding and navigating the medical system at every stage of the care continuum. And we need to understand that education is also a necessary component to normalize conversations around sex, so we want to increase client’s active participation in care decisions so they can make informed decisions about their sexual health and HIV risk. And these services help move these clients along the continuum from prevention to care, and there are entry points to care in each of our programs.
Nick Diamond: One thing that's really exciting about this conversation is that we're convening a really diverse group of stakeholders, from government to community health centers, and the response to HIV, and Juan Carlos, I might ask if you have a question for Dr. Fanfair related to HIV prevention from your perspective, working in community health, you know, with an opportunity to engage government?
Juan Carlos Loubriel: Yes, definitely, Doctor Fanfair, you know, over the past 40 years, there have been many HIV prevention best practices, including condom use and PrEP. And my question is, what do you see as an HIV prevention best practice coming in the next decade and beyond?
Dr. Robyn Neblett Fanfair: I think there could be so many. I do think one that is of interest and it also ties in a little bit to our upcoming question, but when we really look at the revolution, I would say in treatment modalities, it's been remarkable. So this year marks a decade since pre-exposure prophylaxis was approved. And we know that there are still incredible gains to be made in making sure that's accessible to all people, as we know that there are still very large racial and geographic disparities that we see in PrEP uptake. But I'm very excited about the investigations and research going into longer modalities. So if we've just seen long acting injectables for pre-exposure prophylaxis approved almost one year ago and I know that there's a lot of investigations going on into six-month injections or even implants that could be there longer. So I'm really excited to see over the next decade even longer-acting modalities for pre-exposure prophylaxis while we also work very critically to make sure that all of these new modalities are able to reach all populations equitably.
Nick Diamond: So, Robyn, you just spoke about some of these new tools in our toolkit for people who are HIV negative. And I also want to ask you about some of the new and exciting evidence-based strategies that are now working for people living with HIV to achieve undetectable status and maintain viral suppression.
Dr. Robyn Neblett Fanfair: Absolutely. So, you know, it's really critical that people with HIV continue to have access and remain in ongoing, high quality care and continue to receive support services that they need. One exciting strategy is that treatment is prevention, and we now know that undetectable equals transmittable, or U equals U. Just as we were talking about with prevention and treatment, in addition now to several one-pill, once a day antiretroviral regimens, there are now long acting injectables that are available to help maintain viral suppression. The National HIV AIDS Strategy, or NHAS, has recently released a new quality-of-life indicator. And we believe this will be really critical to assessing quality of life measures such as housing, employment, food security, and self-rated health because we know there's more to overall well-being than just viral suppression. A status neutral framework really encourages a comprehensive, whole-person assessment of a person's unique situation, allowing for more tailored interventions. As we spoke before, we really believe that a status neutral approach can help limit stigma. And regarding stigma, if someone has HIV, they may not feel comfortable visiting an HIV-focused provider. They may be concerned about the possibility of being defined only by their HIV status. And they can encounter providers who may not take into consideration all of the other factors that affect their health. So for a person with HIV in a status-neutral approach, health care providers can obtain key information to better link persons to health-related and wraparound services, which will help keep them engaged in care, which can improve their ability to maintain a low or undetectable viral load.
Nick Diamond: Craig I'd like to also bring you into this conversation and thinking about your work at APLA Health, could you talk a little bit about your health center and the HIV care program?
Craig Thompson: Sure. I think the first thing we need to acknowledge is that we talk about the HIV epidemic. But the HIV epidemic is really HIV epidemics, and our epidemics are very different in parts of the country, who we serve, where the growth is, the number of women impacted, for example, or the number of injection drug users impacted, for example is very different. So I'm coming from Los Angeles, which is an epidemic that has been driven from the very beginning by gay men and members of the trans community. So in Los Angeles, the demarcation for us has never been HIV positive and HIV negative in care. It's been around connecting people to LGBTQ+ services. So we market our services as having LGBTQ+ friendly, competent, and that brings HIV negative folks and HIV positive folks into the same services, into the same sites, with the same providers. And so we've been doing status-neutral care from that perspective for many, many years. What we do find, though, is that primary care in a very busy community health center can take a while. And as much as we try to streamline the approach, what we've done now is try to pull out sexual health services, PrEP services, whether for folks who are HIV negative or HIV positive in the case of STD services, and create a streamlined approach for it to get people in and out for sexual health services, so they're not in the pri