Facing a yearlong siege from the coronavirus, the defenses in another, older war are faltering.
For the last two decades, HIV/AIDS has been held at bay by potent antiviral drugs, aggressive testing and inventive public education campaigns. But the COVID-19 pandemic has caused profound disruptions in almost every aspect of that battle, grounding outreach teams, sharply curtailing testing and diverting critical staff away from laboratories and medical centers.
The exact impact of one pandemic on the other is still coming into focus, but preliminary evidence is disturbing experts who have celebrated the enormous strides in HIV treatment. While the shift in priorities is nationwide, delays in testing and treatment carry particularly grievous risks in Southern states, now the epicenter of the nation’s HIV crisis.
Clinics have limited in-person visits and halted routine HIV screening in doctors’ offices and emergency rooms, with physicians relying instead on video calls with patients, a futile alternative for those who are homeless or fear family members will discover their status. Rapid-testing vans that once parked outside nightclubs and bars and handed out condoms are mothballed. And, in state capitals and county seats, government expertise has been singly focused on the all-hands-on-deck COVID response.
Concrete signs of the impact on HIV surveillance abound: One large commercial lab reported nearly 700,000 fewer HIV screening tests across the country — a 45% drop — and 5,000 fewer diagnoses between March and September 2020, compared with the same period the year before. Prescriptions of PrEP, a preexposure prophylaxis that can prevent HIV infection, have also fallen sharply, according to new research presented at a conference last month. State public health departments have recorded similarly steep declines in testing.
That dearth in new data has led to a precarious, unknowable moment: For the first time in decades, the nation’s lauded HIV surveillance system is blind to the virus’s movement.
Nowhere will the lack of data be felt more profoundly than in the South: The region accounts for 51% of all new infections, eight of the 10 states with the highest rates of new diagnoses, and half of all HIV-related deaths, according to the most recent data available from the Centers for Disease Control and Prevention.
Even before the COVID pandemic, Georgia had the highest rate of new HIV diagnoses of any state, though lower than that of Washington, D.C. The Georgia Department of Public Health recorded a 70% drop in testing last spring compared with spring 2019.
The slowdown in HIV patient services “could be felt for years,” said Dr. Melanie Thompson, principal investigator of the AIDS Research Consortium of Atlanta.
She added, “Every new HIV infection perpetuates the epidemic and will likely be passed to one or more people in the months to come if people are not diagnosed and offered HIV treatment.”
Coronavirus testing has commandeered the machines previously used for HIV/AIDS testing, further straining surveillance efforts. The polymerase chain reaction — or PCR — machines used to detect and measure the genetic material in the human immunodeficiency virus are the same machines that run COVID tests around-the-clock.
Over the decades, as HIV migrated inland from coastal cities like San Francisco, Los Angeles and New York, it took root in the South, where poverty is endemic, lack of health coverage is commonplace, and HIV stigma is pervasive.
“There is the stigma that’s real. There is legacy racism,” said Dr. Thomas Giordano, medical director of Thomas Street Health Center in Houston, one of the largest HIV clinics in the U.S. The state’s political leaders, he said, view HIV as “a disease of the poor, of Blacks, Latinos and gay. It’s just not mainstream at the state level.”
HIV clinics that serve low-income patients also face limitations using video and phone appointments. Clinic directors say poor patients often lack data plans and many homeless patients simply don’t have phones. They also must contend with fear. “If a friend gave you a room to sleep and your friend finds out you have HIV, you might lose that place to sleep,” said del Rio of Emory University.
Texting can be tricky, too. “We have to be cautious about text messages,” said Dr. John Carlo, chief executive officer of PRISM Health Care North Texas in Dallas. “If someone sees their phone, it can be devastating.”
In Mississippi, HIV contact tracing — which was used as a model for some local efforts to track the coronavirus — has been limited by COVID-related travel restrictions meant “to protect both staff and client,” said Melverta Bender, director of the STD/HIV office at the Mississippi State Department of Health.
Of all regions in the U.S., the South has the weakest health safety nets. And Southern states have far fewer resources than states like California and New York. “Our public health infrastructures have been chronically underfunded and undermined over the decades,” said Thompson, the Atlanta researcher. “So we stand to do worse by many metrics.”
Georgia’s high HIV infection rate and the state’s slow pace of COVID vaccinations “are not unrelated,” Thompson said.
The porous safety net extends to health insurance, a vital need for those living with HIV. Nearly half of Americans without health coverage live in the South, where many states have not expanded Medicaid under the Affordable Care Act. That leaves many people with HIV to rely on the federal Ryan White HIV/AIDS Program and state-run AIDS drug assistance programs, known as ADAPs, which offer limited coverage.
“As a matter of equity, insurance is critical for people to live and thrive with HIV,” said Tim Horn, director of health care access at NASTAD, the National Alliance of State and Territorial AIDS Directors. Ryan White and ADAPs “are not equipped to provide that full sweep of comprehensive care,” he said.
Roshan McDaniel, South Carolina’s ADAP program manager, says 60% of South Carolinians enrolled in ADAP would qualify if her state expanded Medicaid. “The first few years, we thought about it,” said McDaniel. “We don’t even think about it nowadays.”
Enrollment in the Ryan White program jumped during the early months of the pandemic when state economies froze and Americans hunkered down amid a grinding pandemic. Data from state health departments reflect the increased need. In Texas, enrollment in the state’s AIDS drug program increased 34% from March to December 2020. In Georgia, enrollment jumped by 10%.
State health officials attribute the increased enrollment to pandemic-related job losses, especially in states that didn’t expand Medicaid. Antiretroviral treatment, the established regimen that suppresses the amount of virus in the body and prevents AIDS, costs up to $36,000 a year, and medication interruptions can lead to viral mutations and drug resistance. But qualifying for state assistance is difficult: Approval can take up to two months, and missing paperwork can lead to canceled coverage.
Federal health experts say Southern states have generally lagged behind getting patients into medical care and suppressing their viral loads, and people with HIV infections tend to go undiagnosed longer there than in other regions. In Georgia, for example, nearly 1 out of 4 people who learned they were infected developed AIDS within a year, indicating their infections had long gone undiagnosed.
As vaccinations become widely available and restrictions ease, HIV clinic directors are scouring their patient lists to determine who they need to see first. “We are looking at how many people haven’t seen us in over a year. We think it’s over several hundred. Did they move? Did they move providers?” said Carlo, the doctor and health care CEO in Dallas. “We don’t know what the long-term consequences are going to be.”
The ACHDNC advisory committee provides advice, recommendations, and technical information about aspects of heritable disorders and newborn screening to Health and Human Services. The committee also works to develop policies and priorities that will enhance the ability of states and local health agencies to provide screening, counseling, and healthcare services for newborns and children who have or are at risk for heritable disorders.
DeLuca tells newsstand.clemson.edu, “Being able to be part of this very important process is incredible. People take their cue from the ACHDNC for deciding which disorders to include in states’ screening panels. Each state screens for particular conditions, and I look forward to being able to help with those recommendations.”
DeLuca’s career started in genetics, working with infants identified with metabolic conditions as a result of newborn screening. Now a professor, she collaborates on research with the Greenwood Genetic Center and teaches genetics to undergraduate and graduate students. She also chairs the recruitment committee for the Clemson School of Nursing and is a member of the Women’s Commission at Clemson.
To learn more about Jane DeLuca, an associate professor in the Clemson University School of Nursing who was been appointed a member of the Advisory Committee on Heritable Disorders in Newborns & Children in the US Department of Health and Human Services, visit here.
According to the US Health Resources and Services Administration, South Carolina is projected to have a shortage of registered nurses by 2030. The shortage is expected to be more significant than in most other states, possibly topping 10,000 nurses.
Clemson University’s School of Nursing and the Greenville Health System (GHS) recently collaborated on a plan to address that shortage in the state of South Carolina through the opening of the Clemson University Nursing building. The building is an education and research facility that houses an expansion of Clemson’s baccalaureate nursing program at GHS, which opened in August.
Clemson’s new building allowed the School of Nursing to increase its first-year enrollment from 64 in fall 2015 to 173 in fall 2018. The university expects to increase total enrollment in the baccalaureate program to top 700 by 2021.
Kathleen Valentine, director of Clemson’s School of Nursing, tells Clemson.world, “The collaboration will not only expand our enrollment, but will also integrate teaching and clinical practice in innovative ways that will positively impact nursing education and patient outcomes.”
Nursing students at Clemson take their general education and nursing foundation courses on the main campus during their freshman and sophomore years. Then they are placed into one of two cohorts allowing students to complete their nursing courses in Greenville under the guidance of Clemson faculty and complete their clinical rotations at a GHS campus, or take their junior and senior nursing courses on Clemson’s main campus and complete their clinical rotations at health systems across the state, including GHS.
To learn more about Clemson Nursing’s partnership with Greenville Health System to open a new education and research facility, visit here.
Clemson’s School of Nursing received a grant of $25,000 from SCHA’s Indigo Enrichment Scholarship for its partnership with the Greenville Health System. The university plans to use the funds to help create interprofessional opportunities in the clinical learning environment.The $25,000 granted to USC went to the health services policy and management department of the Arnold School of Public Health. USC will use the funds to support students in the Master of Health Administration program.
Clemson School of Nursing Director Kathleen Valentine tells Newsstand.Clemson.edu, “We’re grateful for the South Carolina Hospital Association’s support of our efforts to ensure that our graduates are well prepared to work at the top of their license as a registered nurse. Through these funds, students will have increased access to experts in the fields of interprofessional teamwork, continuum of care, population health and community health.”
USC Master of Health Administration program director Bankole Olatosi says, “The SCHA scholarship will help the MHA program as it prepares students for positions to advance the provision of effective, efficient and equitable health services in South Carolina. Our students will benefit from the increased access to professional education available through conferences, meetings, and training to complement their education.”
The South Carolina Hospital Association is the leadership organization and principal advocate for the state’s hospitals and healthcare systems. The scholarship program is funded by SCHA Solutions, a division of the hospital association that partners with endorsed companies that provide workforce and operational services to state hospitals and health systems.
To learn more about the South Carolina Hospital Association’s $25,000 grants to Clemson University and the University of South Carolina, visit here.
A nutrition pilot was recently launched at the Medical University of South Carolina (MUSC) to give nurses support to change their health habits, allowing them to better care for their patients. Nurses often deliver health promotion education to patients, but when it comes to their own health habits, they often don’t take their own advice.
The pilot was prompted by multiple studies showing the need for nurses to implement healthier habits in their own lives. A 2011 study at the University of Maryland School of Nursing found that 55% of 2,103 female nurses surveyed were overweight or obese, while a recent survey of nurses at MUSC found that 75% of MUSC Health nurses reported putting their own health, safety, and wellness behind that of their patients. The MUSC study manifested results showing that nurses struggle with healthy eating, including eating less than the recommended daily amount of fruits and vegetables.
MUSC’s nutrition pilot helped the organization’s 2,700 nurses improve their healthy eating habits. Over the course of 60 days, the nurses tripled daily consumption of fruits and vegetables. After the pilot, 72% of nurses reported eating three or more servings of fruit and vegetables a day.
Efforts similar to this pilot have the potential to improve the health of the nursing workforce, as well as the health of patients who look to their healthcare providers for support and advice. Research has found that patients find preventative recommendations from healthcare providers who engage in healthy behaviors to be more credible and motivating
The pilot program was supported by Sodexo, a food and services facilities management company who is partnered with the American Nurses Association’s Healthy Nurse, Healthy NationTM Grand Challenge. The ANA initiative aims to improve the nation’s health by supporting nurses in changing their own health habits.
Bonnie Clipper, DNP, RN, MA, MBA, CENP, FACHE, vice president of Innovation at ANA, stated in a news release: “MUSC Health nurses’ willingness to participate in the pilot and also engage in the planning phase by sharing details about their nutritional habits is the sole reason it was a success. Pilots like this one and other innovative programs that target the nursing workforce are necessary to help create healthy nurses and – ultimately – a healthy nation.”
To learn more about the Medical University of South Carolina’s nutrition pilot to support healthier habits in nurses, visit here.
The building will enable Clemson and GHS to address the critical shortage of nurses in the state, and has already allowed Clemson to increase the size of its freshman nursing class. Clemson’s School of Nursing usually admits a class of 64 freshman each fall, but started this year with a class of 173 freshman.
South Carolina has been one of the states most affected by the shortage of nurses. However, Clemson’s Bachelor of Science in Nursing (BSN) program has seen significant growth in applications over the last ten years. In anticipation of the new building, the university has been bumping up nursing class sizes for two years. Total enrollment in the nursing program will increase from 256 in the fall of 2015 to 704 students as it reaches maximum capacity (when all four classes max out at 176 students).