Member Spotlight: M. Keith Rawlings, M.D., A.A.H.I.V.S.
Addressing Issues of Disparity, Access and Outcomes in HIV Care
The face of HIV is changing. And according to M. Keith Rawlings, M.D., it's time to make corresponding changes in the way the disease is prevented, diagnosed and treated. The American Academy of HIV Medicine, he adds, can help in significant ways by continuing to leverage its national scope, its focus on updated education and its multidisciplinary approach.
Rawlings is a 1983 graduate of the University of Maryland School of Medicine and did his residency in internal medicine at Union Memorial Hospital in Baltimore. He has served as co-investigator or principle investigator on more than a dozen major research projects and has participated in or produced more than 165 peer-reviewed journal articles, abstracts, posters and presentations. And he was just named the National Medical Association's 2004 Internist of the Year.
"My passion about this disease and the basis of my career is making sure that on as many fronts as possible -- clinical care, research, policy, education and advocacy -- people have access to quality care," Rawlings stresses. "Also, it's essential that providers are given the necessary education for whatever changes need to occur to make sure people's treatment and access issues are being addressed."
Rawlings, in fact, has put his proverbial money where his mouth is. In 1998, he created the Dallas-based Integrated Minority AIDS Network Inc. -- IMANI -- to educate clinicians and other providers and organizations around HIV care practice in minority communities. Through the organization, he's also served as principle investigator for the National Minority AIDS Education and Training Center grant.
"For me," he comments, "HIV is a bellwether of many of the issues around health care access in general. It has, in many cases, driven changes in technology and in the way patients and physicians interact." And, he adds, the HIV epidemic has highlighted many of the flaws in the current system. "The ability of people to have access to quality medical care is fundamental," he states. "I have believed for years -- and still do -- that health care is a right, not a privilege, and that individuals should have the right to get quality, affordable medical care independent of the balance in their checkbooks."
Many of the patients who have the most trouble with access have made up his patient base for most of his career. "What drives me specifically about HIV is it has always been about issues of disparity, of access and of outcomes," he says, "and those disparities are often based around the populations that I take care of. They are overwhelmingly minority and poor."
It's been that way for a long time. Rawlings saw his first patient in 1984, he tells The Nexus, noting that "the majority of the people I saw in Baltimore in the mid-1980s were African American, and even back then probably half were African-American women." In 1986, he became medical director at the West Baltimore Community Health Corporation and at the same time began a private practice. In 1998, he went public, taking a position as director of the Office of AIDS Policy Coordination and as chief of medical affairs with the City of Baltimore Health Department.
In 1989, Rawlings headed to the South, establishing an internal medicine practice at Bayou Comprehensive Health Center in Lake Charles, Louisiana, eventually adding the roles of chief of adult medicine and principle investigator for all of the facility's HIV services grants. While there, he worked with the U.S. Public Health Service to set up one of the first Ryan White Title III programs in a rural setting. In 1992, Rawlings relocated to Dallas, where he became, over the course of 10 years at the Parkland Health & Hospital System Community-Oriented Primary Care System, clinical director of the HIV/AIDS Early Intervention Program, assistant medical director for special projects, clinical director of the Cancer Prevention and Intervention Program, and associate medical director. Rawlings also served for 10 years as a clinical assistant professor of internal medicine at the University of Texas Southwestern Medical Center. In 2001, he moved to the AIDS Arms Inc./Peabody Health Center, where he serves as medical director.
Rawlings has strong feelings about how the federal government and its health officials are exploring ways to incorporate more of the patients he's built a career helping. The National Institutes of Health (NIH), he explains, recently held a meeting at which officials updated practitioners on the various research networks they fund related to HIV. Part of that update detailed NIH's efforts to "alter the current mechanisms for how individuals, programs or institutions interact with the federal government research structure," he says. "One of the issues, which I pointed out to the NIH, is, given the demographic makeup of the epidemic, there need to be mechanisms that enable more individuals -- in a manner that reflects the demographics and the epidemiology of the virus -- to access and get involved in clinical research."
The NIH, he points out, agrees that certain populations that are increasingly bearing the brunt of the virus are not included in sufficient numbers. But the government approach, he says, is to simply try to increase participation of underrepresented populations in the existing research framework. "Should we continue to go to the same network of providers, the same investigators and the same programs and try to incorporate more people?" he asks. "Or do we try to change the way we're doing it?" The feds, he argues, have been attempting for years to expand representation of certain populations, but those efforts have been less than successful. Now, he says, "we have a dramatic disconnect between who is impacted by the epidemic and who is actually being studied." And that, he says, has affected researchers' "ability to make correlative determinations from one group to the other."
He points specifically to "the lack of inclusion -- until very recently and now only in a couple of studies -- of women. We've assumed a lot of things about HIV based on data overwhelmingly gathered from men." Basic treatment practices and co-morbidities are issues as well, he notes. "How much adherence do we need to have for antiretroviral therapies to work?" he asks. "Most of the data have come from studies of unboosted drug regimens. What happens when you boost them? What looks like a very simple practice management question needs to be looked at for individual populations." And, he stresses, "some populations have more additional diseases than others. And there are patients who have problems with diseases that aren't necessarily opportunistic infections or that aren't those that we tend to focus on. For example, we talk about hepatitis a lot. How about hypertension? Renal failure? Heart disease? When you look at the epidemiology of the epidemic, you don't readily see the studies addressing the fact that you have a pretty sizable portion of your patient population with other medical issues."
All those concerns, he points out, are questions that must be addressed in clinical practice. And he wonders if they can be properly addressed "without the inclusion in research studies of the people most affected by them." The Academy, he says, can help -- largely through its efforts to help consumers and clinicians find doctors who are HIV specialists and to find treatment programs that are part of the Ryan White system. He applauds the Academy for its focus on the whole range of HIV care providers -- including nurse practitioners and physician assistants -- not just M.D.s. Further, he appreciates the Academy's efforts to certify providers as AAHIVM HIV SpecialistsTM -- he got his certification in 2003 -- because "there's a good corollary between experience and outcomes." He hopes, he adds, that the Academy's roster of certified specialists "becomes a pool of providers who care for patients regardless of what they look like or of their economic status."
This article was provided by American Academy of HIV Medicine. It is a part of the publication The Nexus.