More than 10,000 HIV-positive people nationwide have learned their serostatus since 2007 because of a routine-testing project to increase testing and HIV knowledge in the Black community, funded by the Centers for Disease Control and Prevention. The approach, known as opt-out testing, is being used in several cities with high HIV rates -- including New York, Chicago, Los Angeles, Philadelphia and Houston -- and requires HIV testing to be offered as a part of routine medical care unless a patient declines.
In Houston, where the HIV-infection rate is nearly twice the national average, nearly 900 new cases were diagnosed in less than two years at just a half-dozen emergency rooms and clinics. An estimated 3,500 to 4,500 people in the Houston area don't know they are living with HIV, according to the city health department.
But many experts express concern that inadequate infrastructure exists nationwide to deal with the newly diagnosed. Joseph C. Gathe Jr., M.D., who has been treating HIV/AIDS in Black people since the early days of the pandemic and is one of only a few HIV specialists in Houston, agrees. We asked Dr. Gathe, 53, about his history of treating patients and why he's worried about the future.
How long have you been involved with HIV/AIDS?
I've been dealing with the epidemic in some form since 1981.
What is different in HIV/AIDS today?
The first major problem is that there is nobody to take care of these patients. People aren't dying of HIV, so you need doctors who have some expertise in treating it. If I'm a primary care physician, I have to see a certain number of patients per hour to break even. It takes me 30 minutes to see an HIV patient. It takes me three minutes to see a diabetic. So a primary care doctor is not going to take care of HIV -- not to mention that the disease is changing so much, you've got to work hard to keep up.
How can this happen in the Houston region, home to three medical schools and the Texas Medical Center -- the world's largest community of hospitals and institutions providing patient care, conducting medical research and engaging in health education?
This community hasn't had a new physician treating HIV in the last 10 years, and a ton have exited the field to do Botox and everything else. I've been looking for 10 years for someone to come to work with me. They don't even want to see what it's like. There's going to be a tremendous manpower shortage. If I keeled over dead, where would these 3,000 patients go?
So what happens to the 500 who have been newly diagnosed in Houston under this opt-out program so far and the 50, on average, who learn their status every month?
You can continue to test, but if you do not give them access to the care they need, you haven't done them a benefit. Primary care doctors don't have the time or the expertise to deal with this ever-changing disease.
What steps must the medical field take to produce more HIV specialists?
The only way is if people get paid for doing this. If I can open up a Botox clinic and do a couple of shots for the money I make here all week, there's got to be a differential reimbursement for disease processes like this. You can train somebody to treat HIV, but if another specialty allows them to make more money, they're just not going to treat HIV. The struggle is that these patients never get well. I'm never done.
If you were in charge, how would you create more HIV physicians?
By some initiative where you go back to the medical schools and say, "If you don't graduate two HIV-treating physicians out of each class, we're not going to give you matching federal funds."
How did you get involved with HIV/AIDS?
Quite by accident. When I was training at Baylor College of Medicine, I decided to do an infectious-disease fellowship at the same time that the HIV epidemic was beginning. Gay men and IV-drug users were coming in with unusual infections, and I would end up seeing them because of my infectious-disease background. Little did I know what I was dealing with, but many colleagues my age have accidentally gotten into treating HIV by having all of these patients brought upon us because of our expertise at that time.
When did HIV/AIDS become a Black disease in Houston?
In the late 1980s and early '90s. Many Black patients were diagnosed with full-blown AIDS, but it had taken eight to 10 years of exposure to HIV to get AIDS. When you looked at a person in 1990 with AIDS, that meant HIV transmission took place 10 years before. We didn't have testing until approximately 1984, so we were always looking backwards to determine the demographics. When testing came, we realized that this disease was not one of a high-risk group but of high-risk behavior. So during this so-called gay disease, when the White gay community began to educate itself, it was also running rampant in the African American gay and heterosexual communities because there was not an understanding that this was a disease of high-risk behavior. And because you don't get sick for 10 years, people continued to spread the disease. This fire was raging in the 1980s, and we began to get an explosion in the '90s.
How have the demographics of your patients changed?
We have 75-year-old people coming in HIV-positive -- people who missed what was going on from 1981 to 2001 -- and young people who never saw all the death and devastation. The older people are now, all of a sudden, single again -- widowed, divorced -- and there's Viagra and everything else. So when the 70-year-old guy goes to have sex, he's not going to Walgreens for a condom. The education part didn't reach them. We routinely have 67-, 70-year-old men coming in who are HIV-positive. Do you think the Viagra prescriptions come with that warning on the side of the box? When is the last time Grandpa was in the condom aisle? That's one of the newest demographics. Gay patients and women having unprotected sex are still there.
Isn't prevention more important now?
More than ever, but now there's this sense of complacency because this disease can be treated.
Cindy George is a health reporter at the Houston Chronicle.