An HIV-Free Generation?

An examination room at the Moody Medical Clinic (Photo by Jana Birchum)

AIDS Services of Austin, the region's largest AIDS services organization, opens its first clinic on Aug. 7, to provide a patient-centered medical home for Central Texans living with HIV and fill a gap in Travis county's continuum of care. And the timing couldn't be better. On June 20, Austin and Travis County together pledged to achieve 90-90-90 – that is, 90% of all county residents living with HIV know of their diagnosis; 90% of those diagnosed with HIV getting onto sustained treatment; and 90% of people on sustained treatment having an undetectable viral load (meaning they can no longer transmit the virus) – by 2020.

The 90-90-90 standard was established in 2014 as part of the Paris Declaration, with the intention of eliminating AIDS as a public health threat by 2030. That's a particularly ambitious goal in Austin, a city that sees roughly 250 new cases annually and estimates that 987 residents are positive and undiagnosed. However, Dr. David Wright, an expert on HIV who will serve as medical director of ASA's clinic, said it's one that's "very doable." Getting to zero requires robust prevention tools (including expanded testing and access to PrEP – the pre-exposure prophylaxis that's 99% effective in blocking the transmission of HIV), as well as getting and keeping those who are living with HIV in care. To do so, Austin must make care more accessible. Wright said that, "more than anything else," was what motivated the creation of ASA's Moody Medical Clinic (AMMC).

According to Wright, to understand current HIV goals, we have to look at the city's past. Wright was one of the first doctors to treat AIDS patients in Austin during the early years of the epidemic, because it "seemed to be the right thing to do. ... A lot of the medical community turned their back on these patients." In the late Eighties, he and several other local doctors – including Kind Clinic Chief Medical Officer Dr. Cynthia Brinson – were asked to join the American Foundation for AIDS Research, making Austin part of a nationwide resource and bringing clinical trials to town.

"People don't realize that, at that time, we didn't have a large medical community," said Wright. "In 1985, we only had one infectious disease doctor that was in practice full time." He compared the Eighties to the days before antibiotics, when physicians knew certain patients were going to die. "For a period of time we didn't have drugs, so we just dealt with symptomatic care ... more than anything else, you became empathetic." Medications improved in the Nineties, making HIV a survivable disease. Today, controlling the virus has progressed to where care and prevention strategies can be addressed at a community level.

Yet barriers remain. Through internal assessments, ASA estimates that newly diagnosed patients wait 45 days for an initial medical appointment for medication. The optimal standard of care is 72 hours to 30 days, because newly diagnosed folks who are fast-tracked into care are more likely to stay in care, rapidly decrease their viral load, and feel more empowered to take control of their health. Wright believes this is one of the key ingredients to reaching zero: During the first three months of a new HIV infection, viral loads are "sky high," and it's easy to transmit the virus. "Identify people as close to the time they become infected and intervene to get them on medications," he said. And today's drugs work fast: Within four weeks of continued treatment, viral loads usually become undetectable, which is why testing and outreach are so important.

Falling out of care remains an issue, however; one Wright believes must be tackled before there's any hope of truly eradicating HIV. He hopes AMMC will fill that gap by "changing the dynamics" and "creating a partnership between patient and provider."

Austin is seeing a growing population of people living with HIV. Over the past six years, the rate has increased by 18.6% in Travis County, due to population growth and continued transmission. As Austin grows less affordable, with limited access to public transportation in and around city limits, people living with HIV – especially those who are aging and require specialized treatment – have a more difficult time accessing care. The AMMC, funded in part by a grant from the Moody Foundation, will largely focus on providing testing and linkage to care on-site, and provide primary care, sexual health counseling, and mental health assistance, with services ramping up incrementally. The clinic's soft opening, Aug. 7-31, will offer PrEP prescriptions for up to 40 patients. Their prevention services will work in tandem with the Kind Clinic, which began as a PrEP access clinic in 2015, but has grown into a full-service sexual health, wellness, and gender care medical home. Starting September 5, AMMC will begin serving 50 current ASA clients before opening additional appointments. ASA Execu­tive Director Paul Scott said the organization wants to "get it right from the start" by taking deliberate steps to "avoid overwhelming the clinic in the early phase of implementation."