How do you treat an almost inaccessible population?
Sandra A. Springer, MD has always known that drug and HIV care must be integrated to provide the best care. Unfortunately, those who encounter the most obstacles are “always forgotten,” according to Springer. Poverty, housing instability, involvement of the judiciary, racial stigma and lack of transportation make it difficult for providers to reach these populations in need of care.
“If we don’t figure out how to reach this population and bring them these evidence-based treatment and prevention services, we’re not going to make a dent and the deaths are going to continue,” Springer said.
On June 14, Springer received the Vanguard Award from the National Institute on Drug Abuse, a branch of the National Institutes of Health, for research into HIV prevention and treatment among people who use drugs. Springer’s research plan is modeled after that of the US Department of Health and Human Services. Ending the HIV Epidemic in the United States (EHE), which aims to scale up key HIV prevention and treatment strategies with the goal of reducing new HIV infections by 90% by 2030. EHE includes four elements: test, treat, prevent and predict . Springer’s vision is to close the gaps at every stage and bring substance use disorders, especially opioid use disorders, into the initiative.
At the center of his work will be a mobile health clinic and a pharmacy. It will target people at risk for HIV and at high risk of overdose.
To overcome barriers to testing and treatment, Springer says drugs need to be available where people live — housed or unhoused — and provided by people they trust. The first step is to recruit people living in communities with high rates of HIV and SUD and train them to become community health workers (CHWs). CHWs would be trained to perform rapid point-of-care HIV testing of people in their area and to diagnose opioid use disorders and other substance use disorders. They would then link them to care.
“It has to be people who reflect that community, reflect the people who are affected,” Springer said. She maintains that CHWs can be anyone, even someone without housing. As she prepares to launch the project in Connecticut, she will work with Alliance for Living and the Department of Public Health to help identify CHWs. Word of mouth also plays a role.
If after the test, if patients need care, they will be put in touch with a clinician accessible via telehealth. Clinicians could prescribe drugs that will be delivered in real time from the mobile centers. Medicines will be made available on the mobile hub from retail pharmacies where pharmacists will direct dispensing. Working with CHWs, pharmacists will ensure that people receive their medications the same day if needed, as well as timely refills.
“I think pharmacists are going to be invaluable in that regard,” Springer said. Patients may not have access to a traditional pharmacy nearby, and even if they did, it may not stock the necessary medications. Health insurance, which is necessary for telehealth, is another hurdle Springer is working to address.
For prevention, the mobile response team consisting of a trained CHW, pharmacist and online clinician will rapidly provide PrEP (pre-exposure prophylaxis), medications for drug use disorders opioids and naloxone, and access to needle service programs. Finally, Springer plans to collaborate with scientists to predict where outbreaks may occur in order to rapidly deploy prevention and treatment there.
Put the plan into action
The Avant-Garde Award offers five years of funding. Springer is using the first year to set up the mobile pharmacy, hire community health workers, meet with partners and assess costs. Due to supply chain issues created by COVID-19, it has been difficult to secure a mobile health unit, but Springer hopes to have the unit ready early next year.
The model will first be tested in Connecticut. Since rural areas have fewer resources, Springer will focus its efforts there, starting with Litchfield County. “This is a real-world implementation project. This is not a randomized controlled trial; there is no strict eligibility,” Springer said. “He tries to find the communities and bring the services to them.” Once the model has been evaluated, she plans to introduce it to other parts of the country that have mobile units to see if it can be replicated.
However, these populations in need of treatment face two other barriers: stigma and trust. “There’s a lot of local and community fear,” Springer said. She explained that some people believe that providing drugs such as Narcan for substance use disorders will encourage drug use. “Not all communities are going to accept this.
By partnering with communities, her hope is to provide a wider range of services they might need in addition to HIV and drug treatment. For example, communities with more older people may want blood pressure checks or treatments for diabetes and hypertension.
Stigma is also seeping into medical settings. In some areas, disclosing a substance use disorder can be punitive. And, due to the history of mistreatment of marginalized people, many people seeking treatment might be completely wary of medicine. This is why community health workers are key to the success of the project.
Springer knows these next five years will be tough, but she’s ready.
“A lot of people just give up because it’s a lot of work, but we can’t give up,” Springer said. “We have to understand that.”
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