December 2, 2024
New guidance for primary care providers offers expertise and hope
“They were going from funeral to funeral”—that’s how Marwan Haddad, MD, describes his medical school mentors, the first generation to confront the devastation wrought by a virus known as “HIV.” The first cases in the United States appeared in the early 1980s. In the years that followed, the death toll due to AIDS, the advanced immune deficiency syndrome caused by HIV, was enormous. The community of gay, bisexual and other men who have sex with men was hit hardest of all. Yet other vulnerable communities were also severely affected, including people who injected drugs and those requiring blood products, like people with hemophilia.
Dr. Haddad, medical director of the Center for Key Populations and an international HIV consultant, belongs to the second generation of HIV physicians, the younger set who entered the field on the cusp of new and promising treatments: a combination of potent antiretroviral medications that suppress the virus in a person’s body. These drugs confer a life expectancy that is similar to people without HIV and make it impossible to sexually transmit the virus. PrEP (pre-exposure prophylaxis), another highly effective medication, can prevent a person from acquiring HIV.
Medications, testing, patient outreach—these are some of the tools Dr. Haddad and his colleagues are implementing and scaling up. Inside the clinic, they care for people with HIV and those who are exposed to HIV. Outside the clinic, they work collaboratively to end the HIV epidemic for all.
Since 1981, governments and health professionals worldwide have marshalled a coordinated response to the HIV pandemic. Their goal: to identify and treat everyone with HIV and stop transmissions of the virus. “This is how we end the HIV epidemic,” explains Dr. Haddad, “by ending new transmissions.”
Now, a new publication for primary care providers helps light that path. As one of its co-authors, Dr. Haddad says this updated publication, Primary Care Guidance for Providers of Care for Persons With Human Immunodeficiency Virus: 2024, promises to guide providers more comprehensively in their approach and care of their patients with HIV. Published by the HIV Medicine Association of the Infectious Diseases Society of America, the new guidance is one of the most comprehensive for primary care providers.
What is HIV/AIDS?
Humans acquire HIV, human immunodeficiency virus, by coming in contact with infectious bodily fluids, such as through unprotected sex or by sharing needles during drug use. Left untreated, HIV attacks the immune cells, making individuals with HIV more vulnerable to infection and disease. People with untreated HIV may develop AIDS, acquired immunodeficiency syndrome, which often leads to death.
Unfortunately, despite the enormous investment of people and governments worldwide, the HIV pandemic persists. The number of new infections in the U.S., despite an encouraging 12% decrease from 2018-2022, continues at a high rate, in the tens of thousands every year (31,800 in 2022). “There are consistently new infections, despite the fact that we have strategic tools that can stop these transmissions,” notes Dr. Haddad.
Who is affected by HIV/AIDS?
Most people who become infected are men who have sex with men (MSM). The picture is more complicated when we consider race and ethnicity data. Hispanic MSM now have the highest rates of infection, followed by Black MSM, followed by white MSM. Black women are the fourth most affected group, followed by Black heterosexual men. Overall, over 70% of newly infected people today are Black or Hispanic.
“It really does divide quite dramatically along racial and ethnic lines,” says Dr. Haddad of the U.S. infection rates. “There has been a slight decrease in transmissions with PrEP uptake among white MSM, but we have not seen anything significant enough overall to say that we’re making major dents.” Dr. Haddad explained that the Centers for Disease Control (CDC) estimates that of the men at risk for HIV in 2022, around 94% of white men are getting PrEP, compared to only 24% and 13% of Hispanic and Black men, respectively. (To learn about the lack of PrEP access for Black women and girls and how health centers can play a role in closing the access gap, click here for commentary published earlier this year by some of our colleagues.)
A personal connection
For Dr. Haddad, the interest in HIV is both personal and professional. He came of age in the 1980s when HIV/AIDS, first labeled a “gay disease,” was emerging. Even before he went to medical school, the virus loomed large for him. As he learned about HIV/AIDS and began to understand the virus better, he gained a sense of agency and determination. Charting his course as a doctor, he wanted to give back, he says, “to help with the devastation within the gay community, and all the stigma that was circulating.”
“The virus challenged us as a society on every level,” he adds. “It challenged me as a professional. It was the first chronic disease that was political. It hit every system, and we had to address them all—medical, mental health, social networks, politics. It was harsh and fascinating and brutal.”
An international effort
The U.S. government’s “Ending the HIV Epidemic” (EHE), launched in 2019 under President Donald Trump, is a multi-year initiative dedicated to HIV prevention and treatment, with the goal to reduce new transmissions by 90% by 2030. In 2021, the National HIV/AIDS Strategy, published under President Joe Biden, continued EHE and provided stakeholders across the country with a roadmap for ending the epidemic. In addition to prevention, goals include improving health outcomes for individuals with HIV and reducing HIV-related health inequities.
Meanwhile, across the U.S., primary care providers, including a range of federally funded health centers, are doing more and more of the important clinical work related to HIV. Dr. Haddad and his co-authors wrote the new guidance for them and their patients.
A guidance designed for primary care
While this is not the first HIV primary care guidance, it is quite comprehensive, with updates and entirely new sections. The panel of writers convened for months to discuss and review the content. The new guidance includes information on cancer screenings, bone density, substance use and harm reduction, sexually transmitted infections, vaccinations, mental health, adolescent and pediatric treatment, street medicine, and more. It also addresses systems-related issues such as patient-centered, team-based models of care, reducing stigma, and increasing equity.
“It’s an incredible document,” says Dr. Haddad, who took the lead on a section entitled “Routine Health Care Maintenance Considerations for People with HIV.”
“Primary care providers can refer to one document,” he continues, “and receive guidance on all aspects of delivering HIV primary care to their patients.”
That’s the idea: to build a community of practitioners with the same information who share the same strategies and goals. By designing special guidance for primary care providers, Dr. Haddad and his co-authors are reaching an audience well positioned to stop new transmissions and hasten the end to an epidemic that is approaching its grim 50-year mark.
Someday a cure may come
Reflecting on the change that has taken place over the decades, Dr. Haddad recalls the moment in the mid-1990s when game-changing combination antiretroviral medications became available, rendering HIV a treatable chronic disease.
“The medicine brought so many people back from their deathbeds and gave them a chance to live normal lives,” he explains. “It was a very exciting time. I came into HIV medicine when there was much more hope. We don’t have a cure yet, and that may or may not eventually come.”
“But regardless of a cure,” he concludes, “these days nobody should get HIV. Nobody should die from HIV. People are still getting infected, and people are still dying. We need to ensure that everyone is able to access the healthcare they deserve, engage them in care, and maintain them on the treatments they need. I hope the new guidance will help expand quality HIV care and extend life to more people. By sharing knowledge, we can make a difference.”
The Center for Key Populations, where Dr. Haddad serves as medical director, is a program of Community Health Center, Inc., the clinical affiliate organization of the Moses/Weitzman Health System. To learn about Dr. Haddad’s virtual ECHO clinic at the Weitzman Institute, visit this page.
