In Black America; HIV and AIDS, with Dr. Laura Cheever

From the University of Texas at Austin, K-U-T Radio, this is in Black America. We're actually celebrating our 30th year of the Rhywit program this year, so it was 30 years ago this year in August that the bill was signed into law. It is a great program. It's a program that was named after Rhywit, not of Rhywit, who really fought against that stigma. And the program is really unique because first, the way the program works is people in the local communities decide how the funding is spent when it comes there. They do an assessment to figure out what they need. And the funding provides money for medical care, as well as medications, and the support services that people that are living at or below the federal poverty level need to get into care and stay in care. Things like transportation, emergency housing, if they need it, emergency food, case management,

those kinds of things that if you're really struggling every day to get your basic needs met, that could interfere with your ability to get medical care. So we try to help people with those basic needs. Dr. Lorde W. Chieber, MD, position and associate minister to HIV, AIDS Bureau, health resources and service administration. On February 7th, 2020, we commemorated the annual observance of the National Black HIV, AIDS Awareness Day. New Ryan White HIV, AIDS program data shows that a record number 84.1% of African-American receiving HIV medical care are virtually suppressed. The Awareness Day was an opportunity to increase awareness of the care and treatment services for African-American facing stigma and HIV related health disparities and encourage those who are undiagnosed to get tested for HIV and if they test positive, get in care and on medication. In 2018, African-Americans accounted for 13% of the U.S. population, but 42% of the 37,832 new HIV diagnosis in this country and dependent areas.

I'm John L. Hansen, Jr. and welcome to another edition of In Black America. On this week's program, HIV, AIDS and the African-American community with Dr. Lorde W. Chieber, associate administrator for the HIV, AIDS Bureau, health resources and service administration in Black America. About 250,000 are not in care. They know they have the infection and they're not in care yet and about 150,000 have yet to be diagnosed and we need more resources to reach those people. This administration, last year, recommended a Congress to increase us by $70 million in this year and Congress did give us that money to try to reach those people that aren't yet in care or if they're in care, that 13% that aren't yet reached sufficiently to be virally suppressed and responding well to treatment. That's so much money to give us this year Congress and next, for this coming year, the administration has requested that we get $165 million more. So we are asking for increasing amounts of money so that we can really do the work that we have yet to do.

And if we get that funding and we're able to do that work, we, I mean, you all, people in the community in Austin and across Texas, across the United States. If we get the money we need to do that work, we think that we, you know, looking at the numbers we have and working with the Centers for Disease Control, CDC, we think that we can really end this epidemic in about 10 years in this country. 1 in 7 African Americans with HIV are unaware they have it. People who do not know they have HIV can't take advantage of HIV care and treatment and may unknowingly pass HIV to others. African American men and women have higher rates for some sexually transmitted diseases than other racial ethnic communities. Having another STD can increase the person chances of getting or transmitting HIV. The poverty rate among African Americans is high. The social economic issues associated with poverty included limited access to high quality health care housing and HIV prevention education directly and indirectly increased the risk for HIV infection and affected health for people living with and at risk for HIV. This passed February the Ryan White HIV AIDS program commemorating the annual observance of the National Black HIV AIDS Awareness Day.

The observance was an opportunity to increase awareness of care and treatment of services for African Americans facing stigma and HIV related health disparities. Recently in Black America, spoke with Dr. Laura W. Chieber, MD, position and associate ministry to HIV AIDS Bureau, health resources and services administration. I was born in Bethesda, Maryland in the Naval Hospital there. My father was the college commissioned officer, worked in public health and I was raised. I grew up in Brazil. We lived in Egypt for a little while so all around but came back to Bethesda and went to high school there and that's the first part of my story. I've worked in San Francisco, I've worked in Baltimore, I'm working out of Rockville, Maryland right now. And what initially sparked that interest in medicine? I was really interested in social justice. I'd been raised by parents that were always sort of talking about the inequities in the world and I really got to see it living in different places. And so I was very interested in social justice and over time realized that health was just a basic foundational piece of people, a living productive, healthy, high quality lives.

And when I was in San Francisco, I was doing my residency there and I really saw how the health system could help people that were really disconnected from society get connected in really meaningful ways. Before Brown University and your medical degree, what other universities did you attend? So actually I started at Brown undergraduate, I got into a special program that from high school they say you can go to medical school if you want, if you do well enough. So I stuck with it all the way through taking some time off to go work in Brazil in the Amazon and other places once again looking at how people were impacted by certain kinds of diseases that were really related to poverty and living in substantial housing. What was it about infectious diseases that sparked your interest? So I actually thought I wanted to go into women's and child health and when I went to San Francisco to my residency and I saw the impact of HIV and really the health disparities of HIV. I really decided that I did not need to go anywhere else in the world. I could stay in the United States and really work on trying to work on a disease that impacted people.

And now really today really huge disparities based on income and race and where you live. How long have we been speaking about HIV A's in this country? It really, it was really in the early 80s, 82 that people started understanding that there was something different going on in the very early days. Our government was remarkably silent about it. It took a long time for our government to acknowledge that HIV was a real thing and we needed to be dealing with it. I'm talking about sort of at the highest levels of government. So I would say since the early 80s we've been tackling this but it all really changed in the 90s when we had really effective therapy. Talk to us about some of the stigmas that has been attached to the disease. Oh, there is huge stigma with HIV. So in the very early days because we had such good epidemiologists and really the best minds, the Centers for Disease Control and people in universities thinking about it, we quickly understood that it was a virus that was transmitted primarily through sex but it could also be transmitted through sharing needles and dirty medical equipment.

So that was the first piece that we understood. But even when we understood that there was a tremendous stigma around having HIV could be more scared of getting it even though we knew you couldn't get it through casual interactions. Ryan White was a young boy who contracted it through blood transfusion and all he wanted to do with when he was first told he had it, he was told he had six months to live and all he wanted to do was to go to school and his community would not let him do that. Even though it was clear that no one would get HIV from him in school. And today I can tell you I still see patients in Baltimore. I was there this morning taking care of patients. And I've got patients that I take care of who have to use paper plates when they go to their relative houses because even though it's been in Baltimore for many years, and people should know now about what the disease is and how you get it. They're still a huge stigma attached. When was the Ryan White HIV AIDS program initiated?

Well, that's a great question. We are actually celebrating our 30th year of the Ryan White program this year. So it was 30 years ago this year in August that the bill was signed into law. It is a great program. It's a program that was named after Ryan White, not of Ryan White, who really fought against that stigma. And the program is really unique because first the way the program works is people in the local communities decide how the funding is spent when it comes there. They do an assessment to figure out what they need. And the funding provides money for medical care as well as medications and the support services that people that are living at or below the federal poverty level need to get into care and stay in care. Things like transportation, emergency housing, if they need it, emergency food, case management, those kind of things that if you're really struggling every day to get your basic needs met, that could interfere with your ability to get medical care. So we try to help people with those basic needs. Talk to us about the level of funding. Is there enough for making do with what you have? Well, that's a great question. So overall across the country, we are funded at $2.3 billion annually, which might seem like a lot of money.

But when you spread it around, we take care of about 500,000 people, over half a million people actually, which is about half of all the people with diagnosed HIV in the country. And we help provide medications to over half the people that are on medicines. So that money gets stretched pretty thin. The issue we have is that among people that are in care that come into a clinic at least once in a year, we do great. We have 87% of those people that come into care are going to get on medication and respond really well and be well taken care of. But we know that of the 1.2 million people are living with HIV in this country, about 250,000 are not in care. They know they have the infection and they're not in care yet. And about 150,000 have yet to be diagnosed. And we need more resources to reach those people. So this administration, last year, recommended a Congress to increase us by $70 million in this year, and Congress did give us that money to try to reach those people that aren't yet in care, or if they're in care, that 13% that aren't yet reached sufficiently to be virally suppressed and responding well to treatment. So that's so much money to give us this year Congress. And next for this coming year, the administration has requested that we get $165 million more.

So we are asking for increasing amounts of money so that we can really do the work that we have yet to do. And if we get that funding and we're able to do that work, we, I mean, you all, people in the community in Austin and across Texas, across the United States. If we get the money we need to do that work, we think that we, you know, looking at the numbers we have and working with the Centers for Disease Control, CDC, we think that we can really end this epidemic in about 10 years in this country. When you speak of care, are these individuals apprehensive of receiving care, or they just don't want any care at all? So if the people that know they're infected and are out of care, we don't know all the reasons. I mean, I can tell you some of the reasons that we don't know the study. So we know that people that are in and out of prison in jail, that is a real disruptor to your life, and if you're getting really good care either in prison or on the outside and you go one way or the other, that can be a bad transition and people can fall out of care for period of time. So that is the way people fall out of care.

We know that there are people that I have a patient several years ago who told me that he would rather die of HIV than let his wife know he had the infection. So there's a lot of shame and stigma that keeps people away. We know that people that have significant mental health issues and substance use issues are often prioritizing other things in their life. And we know that there's just in addition to stigma around HIV, there's a lot of homophobia left in this country, and there's racism. So you add homophobia, racism, stigma around HIV and poverty, and that can just be overwhelming for someone to overcome. So I think those are all important issues that we're going to need to work on in the next few years. I understand. If you're just joining us, I'm Johnny O'Hanston, Jr., and you're listening to In Black America from KUT Radio, and we're speaking with Dr. Laura W. Chivers, position associate administrator HIV AIDS Bureau, health resources, and service administration. Dr. Chivers, how has African Americans become the new face of HIV AIDS?

Yeah, so that's a great question, and it's certainly really frustrating. The impact of HIV in the African American community is hugely out of proportion to representation in the United States. An African American man today has about a 1 in 20 chance of receiving an HIV diagnosis in their lifetime compared to a white man that's 1 in 132. Likewise, an African American woman has about a 1 in 48 chance of developing HIV compared to a white woman that's 1 in 880. It's really among African American men, it is more concentrated among men who are sex with men. For an African American man who's sex with other men, he has about a 1 in 2 chance of getting HIV in his lifetime. So huge risk. Why that is, it's probably several things. One, we know that this has really become concentrated in people that are lower income in this country. African Americans are often lower income than others, and they've less access to medical care.

So that's a major thing. As well, there's more STDs, particularly gonorrhea in African Americans, and that can help in both gonorrhea and syphilis, and that can help spread HIV infection. So I think those are some major issues. You know, African Americans, if you look at things like hypertension, diabetes, other things, they have worse medical outcomes in a higher burden of disease. And a lot of that has to do with less financial resources and lower access to medical care. Now we know there's health care delivery disparities in this country. How is that affecting African Americans who are unaware that they may have contracted the disease? Absolutely. So we know we have health disparities, and that definitely impacts people's ability to get diagnosed with HIV and to get into care. So we have really are working closely with the Centers for Disease Control CDC that does a little bit more testing than we do, as well as with community health centers, which exist around this country, and serve millions of people to increase testing. HIV testing needs to become a routine part of care.

When you go to your doctor, you should be tested for HIV if you haven't before, and that's not happening. People come and sick in the hospital, and they're getting all sorts of blood tests, and if they're living in an air with a lot of HIV, they should be getting an HIV test, because the CDC has been saying that for more than 10 years, and it's not happening in most places. So we really need to turn up HIV testing, where it becomes a routine part of what happens. We see in women where it does happen, pregnant women get tested for HIV, and when that happens, women get diagnosed much earlier in their disease, they're able to get on to treatment. And that's important, because people that are on treatment, and taking their medication every day, become vitally suppressed, live in near normal lifespan. It's not a death sentence like it used to be, but people need to get tested in on to treatment. Well, women usually take better care of themselves, health-wise than men. Yeah, that's been a really tough nut for us to crack. We were trying to figure out, you know, looking internationally, they were trying to figure out how do they reach men better to do HIV testing and treatment, and one of the ways they're looking at is, you know, really going to the, you know, the mothers of those men, and getting the mothers to start talking about HIV with their sons, because maybe they would be able to convince them that they start needing to get medical care. A young man in particular, don't see the doctor about anything where his most young women are going for birth control to get their pap smears and other things.

With new pharmaceuticals out there, how is the depression rate for African-Americans and overall with HIV-AIDS clients? Yeah, so in the Ryan with HIV-AIDS program where I said we provide both medical care and services like transportation to medical appointments, overall nationally, our viral suppression rate is 87%, which is much higher than the national average of everyone that is HIV diagnosed, which is about 63%. But in our program, even with all those supports for providing, we still see disparity. African-American patients, their viral suppression rate is about 84%. So not quite as high as the overall average, however, the great news is from since 2010, when we first started keeping the statistics to today, the viral suppression rate nationally has increased from about 69% to that 87%. And similarly among African-Americans, we've really been able to reduce the health disparities and improve viral suppression rates from African-Americans when we compare 2010 to 2017.

So we're closing the disparity gap, absolutely closing it, but we still have a little bit of a gap of a few points as I just discussed. Is the rate of those who contracted disease going up, going down, or leveling off? That's another really good question. So overall nationally, we still have about 40,000 new infections every year in this country. 40,000? About 40,000. It was 37,832 in 2018. So about 40,000, and that has not changed very much in the last few years. And that's really frustrating. That shouldn't be happening. But when we look at specific groups, we can see that overall among African-Americans, the number of diagnoses among African-American women from 2010 to 2017 decreased by about 27%. And for African-American heterosexual men, it decreased by about 32%. So we've had great changes there. The problem is that among gay and bisexual African-American men, the rate has gone up, and those between the ages of 25 and 34, it's gone up by 42%. So increases there.

Overall, among gay and bisexual men, it's remained stable if you count everyone of every age. But when you look at that one age group, it's been going up considerably. So we need to be doing things differently there. Is there any particular area of the country that's more susceptible than another? Yeah, there's been a lot of work done in the last few years that have shown that overall the South and the Southeast in particular, we've not had as good a control of the infection. And I think some of that has to do with the things we've been talking about. There's less access to medical care. And many of the states where we have worse outcomes in terms of our suppression of HIV, they haven't expanded their Medicaid program. So they're more reliant on their funding from Ryan White and other sources. And as long as we have less access to care and more poverty, we're going to have more HIV. Do you all deal with families or individuals once it comes to the disease?

Yes. So our program, we try to, in most places, provide patient centered care. So it's really centered around the patient and what they want. So in terms of services for people through our program, our program provides medical services only to people that are living with HIV. But we provide support services to family members. And like, for example, if we have for take care of a woman and she gets on medication and she is pregnant and she has a child and the child does not have HIV, we will provide services to that around, you know, to that mother and her child and to that sort of family grouping. So we do provide some services. We certainly encourage people to engage their family members, to disclose to their family members and help have their family members help them stay in care. Because it takes a lot to get, you know, take pills every day of your life, meaning making sure you're getting to the pharmacy on time, getting your refill done, making sure your insurance is still good. You know, there's like a lot of steps involved. And so it really is helpful if you have someone that's supporting you and sharing you on if you do that.

Speaking of pharmacy, how has the price of the pharmaceuticals been for the last 30 years going up, going down, we have new ones on the market? Yeah, so we've the great news is that we have great new drugs for HIV on the market. It's been a lot of research done. And so now most people diagnosed with HIV can be on one pill once a day. Okay. And back when we first had these really good therapies, people had to be on like literally a handful of pills and take different pills, you know, five or six times a day. So now we're talking of one pill once a day, very few are in no side effects. So it's amazing. The cost of medication has been increasing in this country across the board for, you know, every medicine, every type of medication, including HIV medicine. So that the prices there continue to go up. We do have in Ryan White, we're able to use some government programming to help reduce the cost of medicine. In terms of when we're when our states that are buying the medicines for people in the states, they can get a reduced price on the medicine through a special program called the 340 B program. So we don't pay full price for the medicines through a program. And as of now, we've had we've had enough funding to be able to make sure everyone that needs medicines can get medicine through our program.

We've been speaking about African Americans. How about the other populations in the country? Yes. African Americans are certainly have the highest burden of disease. Other populations that have sort of increased rates of HIV include Hispanics, but not certainly not at the rate of African Americans. Hispanic men and Hispanic women have higher rates than white men or white women. And we've been seeing, although they still are very small numbers, significant increases among Native Americans. So those are, I said, the numbers, the overall proportion is still pretty low, but they're increasing in that we don't want to be seeing that in a setting where we definitely have made some good progress among some populations and not others. We work closely with the Indian Health Service to try to work with tribal groups to try to reduce those rates. Going forward and looking forward, is there any level of achievements you all look at with the Ryan White program?

Yes, we look at several things. The first thing we look at is that we are serving the populations we seek to serve, which are, you know, the people living with HIV who are underserved populations. So we make sure that majority, you know, three quarters of the people we see are racial and ethnic minorities. Two thirds are living at or below the federal poverty line. So we know we're seeing, we're taking care of the people we want to take care of, and not just the people that might naturally come to care. So we do a good job with that. We also look at our viral suppression rate, which I said is, are we making sure that the people that come into care are getting on treatment and are taking their medicines every day? They've access to it, meaning they're getting transportation. They have access to their pharmacy and that sort of thing. So we definitely are looking at that, and we look at the viral suppression rate because people that are really suppressed will live in their normal lifetime and have effectively no risk of transmitting HIV to someone else. So right now, our viral suppression rate among African-Americans is 84% and that's great because it continues to improve, but we still have a disparity compared to the overall national rate of 87%. So we still, we focus very much on reducing health disparities, you know, thinking what are the special needs of African-American men and women that might be different? How can we better meet the needs of the people who are not currently meeting their needs fully?

So those are the sorts of things we look at. For a lay person, explain to me what is viral load? Yeah, that's a great question. So viral load is really the measurement of how much virus we can find in a person's blood. So when someone is infected with HIV, they're never cured because the HIV sort of gets into their cell and can lie dormant in their cell for many years. That's what we can't cure someone of HIV, but there is HIV floating around in the cell and that we call viral load. And so we measure that through blood tests and our goal is to have viral suppression, which means your viral load is so low we can't measure it. It's like less than 50 copies of virus in a milliliter of blood. So a very, such a low, minute level that we can't actually measure with our current measurement techniques. And we know that viral suppress people, you know, that is the key. They will live in near normal lifespan and have effectively no risk of transmitting HIV to someone else. And that's such an important message because so many people with HIV feel so much shame and have a lot of internal stigma about having HIV.

And if you say, but yes, but you're not going to pass it on sexually to someone, it really helps relieve a lot of that anxiety people have. When we talk about funding, how are local groups can get in contact with you and what type of groups are a part of the funding program that you all offer? Another really good question. So the way our law is written and our program provides funding based on a law that was passed 30 years ago and has been revised a few times. We give funding to every state, Puerto Rico, the Virgin Islands. So we give funding to those people proportional to the number of people they have with diagnosed HIV. We also give funding to highly impacted cities. And we have several of those highly impacted cities, Houston, Dallas, Austin, San Antonio. So in Texas, those are the highly impacted cities. They also get direct funding. And that funding by law goes to the mayor or the chief elected official if it's a judge in Texas. So it goes to the chief elected official and we give funding to those cities and those cities have to have planning councils, which are people living with HIV and others who come together and plan and prioritize how that funding is spent.

So the chief elected official, the mayor or the judge doesn't decide that the people on this planning committee decide what the priority is in terms of medical care, dental care, psychiatric care, mental health services. And then from there, the city or the state has a procurement process we call a way that they give out contracts, usually through a competitive process. So that's how most of our funding goes out. A small amount of our money goes to universities to train clinicians, and that's called the AIDS Education Training Center Program. And a small amount of our money goes to community-based organizations directly to clinics to provide medical care to people living with HIV. So those are the primary funding streams. The money that goes out to clinics goes directly to community-based organizations. And we have a competition every three to five years to fund areas where we're currently giving out money. So it's a competitive process to see who will be providing care in those areas.

Dr. Laura W. Chieber, MD, Physician and Associate Administrator, the HIV AIDS Bureau, health resources and services administration. If you have questions, comments, or suggestions at your future in Black America programs, email us at inBlackAmerica at kut.org. Also, let us know what radio station you heard us over. Remember to like us on Facebook and to follow us on Twitter. The views and opinions expressed on this program are not necessary, those of this station, or of the University of Texas at Austin. You can get previous programs online at kut.org. Until we have the opportunity again for technical producer David Alvarez, I'm Johnny on Hanson, Jr. Thank you for joining us today. Please join us again next week. CD copies of this program are available and may be purchased by writing in Black America CDs. KUT Radio, 300 West Dean Keaton Boulevard, Austin, Texas, 78712. That's in Black America CDs, KUT Radio, 300 West Dean Keaton Boulevard, Austin, Texas, 78712.

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