In his relatively short time in HIV care, the Pennsylvania native (he grew up on a horse farm in a suburb of Pittsburgh) and 1999 graduate of Rush Medical College has already made quite an impression. One colleague noted an especially difficult patient who, despite being repeatedly hospitalized and slipping close to death, refused to take HIV medications. Dr. Zawitz took the man in as his personal charge, earned his trust, and over time, convinced the man to begin HIV treatment. The man's condition is now stable.
How long have you been practicing?
I completed my Infectious Diseases Fellowship at Rush University Medical Center in Chicago in June 2004, and started attending at Cermak Health Services (Cook County Jail) in July 2004. I have been indirectly involved in HIV care since 1995, and began caring directly for HIV-positive patients as a senior internal medicine resident at University of Pittsburgh Medical Center in 2001-2002. At Rush during my fellowship, like all Infectious Diseases fellows, I had my own HIV clinic patients at the CORE Center (a joint venture outpatient HIV hospital associated with Rush and Cook County Hospital) for the past two years prior to starting full-time at the jail.
Can you describe how your work has changed since you first started?
Since I am a new attending physician, the only comparison I can give is to the work I did as a fellow/resident. As a trainee, I worked at the Veterans Administration (VA) Medical Center in Pittsburgh. This was a substantially smaller center in terms of HIV patient volume and demographics, as compared to both the CORE Center and the Cook County Jail. At the VA, I was, of course, supervised and used the clinic primarily to learn and sharpen my skills. At the CORE Center, I carried a patient load of approximately 150 patients. This setting was independent in that there was a supervising attending available if needed, but I was free to make clinical decisions on my own if I felt comfortable doing so.
The change since completing training has been interesting. I never went through all those years of school and residency/fellowship thinking I'd be working in a jail. The patient population I work with is almost identical to those I care for at the CORE. In fact, I still maintain a clinic one day a week at the CORE where I see the releasees from the jail as well as Illinois state prisons.
Why did you choose to specialize in HIV?
This is a complicated question/answer, but I'll try to keep it relatively basic and, if you need me to flesh it out, I will be happy to do so. There are two main reasons I chose HIV:
What made you decide to work in a jail?
My decision to work in a jail was more of a coming together of circumstances than a conscious career direction at first. At the conclusion of my infectious diseases fellowship training, I knew I wanted to practice HIV primary care and I knew I wanted to stay in Chicago. Naturally, this limited my potential job opportunities. By luck, my predecessor at the jail (Dr. James Cunningham) was planning his retirement. Our paths crossed at the CORE Center, where I had my primary care HIV clinic and Dr. Cunningham saw jail/prison releasees at the continuity of care clinic. I shadowed him for much of my second year of fellowship, and decided I could see myself managing this patient population as a career. Voila.
Tell me a little about the kind of patients you are you seeing.
I see a blend of treatment-naive, treatment-stable and heavily treatment-experienced patients (adult male and female). They come from all over the city (and beyond). Many of them already have primary HIV providers, and because of my position, I have had the pleasure of being able to contact and network with many of them. As one would expect, a high percentage of these patients also have substance abuse or psychiatric issues.
Patients who do not already have a primary HIV doctor are offered referrals to our continuity of care clinic at the CORE Center, as well as to a number of other clinics that may be more conveniently located, depending on where in the city the patient lives.
What kind of crimes did most of the people you see commit and is it a state or federal prison?
I work in a jail, not a prison. It is the Cook County Jail in Chicago (the largest single-site correctional facility in America). These are not federal detainees (they go to a separate holding facility in downtown Chicago). There are a variety of criminal charges assessed. I rarely (if ever) know if a crime has actually been committed. These detainees are people who have been arrested and charged with a crime, but have not yet had their day in court, so they are all innocent until the judge decides. Most are charged with drug-related crimes such as possession or dealing drugs. Other than that, take your pick! Domestic abuse, traffic violations, assault, gang crimes, arson, murder, even necrophilia! I have never ever asked the patients what they have been charged with as part of my clinic "etiquette," although some people will volunteer this information. Unlike medical information, criminal charges are a matter of public record, so if a patient is especially "intriguing" to me, for whatever reason, I can look up their charge in our computer system. Sometimes this is useful to know because, if they have a "simple" charge or have a low bail, I might anticipate they will be released sooner than someone with a serious charge, such as murder or a crime against a police officer. This is important when making treatment decisions.
When your patients leave prison, is there transitional care?
Yes, as I mentioned above, all patients, regardless of whether they already have a doctor or not, are offered a referral to our continuity of care clinic at the CORE Center in Chicago. In some cases, if a release date is known, an official appointment can be made before their "reentry" into the community. If they do not wish to come to our clinic, they are offered a variety of alternative sites around the city, and our door is always open if they change their mind. We have a dedicated "reentry coordinator" who works directly with our patients to improve follow-up at our clinic. We also have some linkages to non-medical referral centers around the city, including drug treatment/rehabilitation, homeless shelters, work release programs, etc.
Is there HIV prevention done with HIV-positive people before they leave prison?
Yes, of course. In addition to what I or my partner Harry Przekop (physician assistant) tell them in the clinic, we have a team of "health educators" who work to answer additional questions and solidify their understanding of their disease.
How do you think that your patients do in terms of staying on treatment when they leave the jail?
When they leave the jail, they go to one of two places: home, or to prison. If they go to prison, I generally have no idea if they are adherent or not until they complete their sentence and someday later show up at the continuity of care clinic at the CORE Center. Most of the patients who show up after release from prison are, in fact, very adherent since their medications are practically DOT (directly observed therapy) while in prison (meaning they are given their pills as they need them and take them in front of someone).
Usually, they are given a month-supply of their meds upon release, and it is the patients' responsibility to make and keep an appointment in time to get a refill. We have a dedicated clinic coordinator at the CORE who acts as a linkage to the 30-plus prisons around the state to assist the docs downstate with making follow-up appointments when discharge is anticipated.
Those who go HOME from the jail ... tougher question to answer. A high percentage of these releasees "disappear," meaning we never see or hear from them again unless they get arrested again (which happens frequently). Those who show up at our clinic at the CORE Center are generally pretty adherent patients. Just the fact that they show up at all signifies they are interested in their healthcare and are more likely to adhere to meds than the people who vanish.
I know in general that you cannot give condoms to people in prison because they are not supposed to be having sex. Is there anything you do to prevent HIV transmission in the prison you work?
Condoms are not given out in jail for more reasons than "they are not supposed to be having sex." It is a much more complicated issue than that (and I, like most people who don't spend time in jails, did not know this). The BIGGEST reason condoms are not available in jail is because they are a security risk. You and I hear this and say "What?". This is because we don't think of the OTHER things condoms can be used for.
For example: string several condoms together and you have a very strong rope to strangle someone with (a correctional officer, a cellmate, a rival gang member, a doc?). You can hide contraband objects (especially drugs) in them and swallow them. Melt them down with a lighter and when they cool it is as hard as steel and can be made into knives, etc. See where this is going? Healthcare is obviously an important issue in corrections, but security trumps all. As far as reducing transmission? I have not seen much evidence in my 10 months that there is a lot of transmission occurring in the jail. Given the sheer volume of HIV-positive people that rotate in and out, one might expect to see more. So far, I can only say I have one patient I can confirm who turned positive in our jail. This patient claims he got it from making a homemade tattoo in his cell with a cellmate who was HIV positive. This is not to belittle the risk of transmission ... even one case is too many. Like I mentioned before, we have a team of health educators who work on the various divisions around the jail to educate the detainees (both the HIV positive and negative). I believe most of the detainees who test positive in jail were positive BEFORE they came in (intravenous drug use, sex with prostitutes, multiple sex partners, BEING a prostitute, plus all the expected risk factors as well).
Tell us more about what it means to work in a jail. What percentage of the detainees are HIV infected?
The last comprehensive serosurvey was performed in 2001. At that time, approximately 2.6% of the detainees (total census was approximately 11,000) were found to be positive.
Does the jail regularly test?
Testing is voluntary. Detainees are screened for a variety of medical issues during intake and if HIV risk factors are identified, testing can be performed with ELISA after pre-test counsel is given by a health educator or provider.
Is it up to the people who know they are HIV positive to come to you for care?
Yes. Anyone who knows they are HIV positive must inform someone (either at intake, or at any time they feel comfortable) in order for us to know to bring them to our clinic for an evaluation. Once they are identified, a consultation is usually delivered to us within 24 hours in most cases.
You said that there are approximately 150 known HIV-positive detainees on any given day, and that, over a course of a year, you see 1,000 new faces in your clinic. Can you explain this?
On any given day, there are 11,000 detainees on site. Roughly 2.6% are HIV positive. Perhaps one half to two thirds of them actually KNOW they are positive, so, naturally, the only ones we are aware of are the ones who know themselves and identify as such. Since testing is voluntary, many of these potential patients are unknowns.
The jail population is highly transient. People are incarcerated with us on average only nine days. We see anywhere from four to ten "new" faces four days a week. Some of these "new" faces are people we have never met before, and some are recidivists (we saw them perhaps earlier in the year and now they are again in jail).
Also you said that if they are still in jail, treatment will be delayed until release? Why?
I think you must have misunderstood something I said to come up with this comment. Treatment decisions are individualized for each patient. If someone comes through intake and knows their meds and doses, the intake doctor will, of course, write the scripts to minimize the chance a dose will be missed. If the patient does not know their meds or has not been taking them for whatever reason (most often because they are using drugs), the intake doctor will defer treatment decisions to our clinic. When we see the patient, we will check baseline labs, including CD4 and viral loads. Many detainees do not meet "guideline" criteria to start. Those that do are challenging. Since they may be going home or to prison or staying with us in the jail for months, we have to consider first their "disposition" issues.
I am not comfortable arbitrarily starting meds on anyone who comes to my clinic just because they have low T cells (but I will start them on prophylaxis if needed). Most of the time, it is the first time we are meeting. I wouldn't start antiretroviral meds on a patient in my clinic on the outside on the first visit, either. I need to properly assess their mental health, substance abuse issues, housing situation, support and social network, etc. before I can make an intelligent decision about when to start. Many of them don't want to take meds while they are in jail for lots and lots of reasons. I can go on and on and on about why someone should or should not start meds in jail.
Examples of reasons why detainees do not want to take meds in jail: Some medications are easily recognizable by other detainees (thus compromising confidentiality). Some side effects (such as diarrhea) are magnified in a setting where 50 men have to share a single bathroom. Some detainees do not want to carry a supply of pills on their person (they do not have "personal space" or places they can leave their meds during the day). Some would just rather "wait until they get out." Some have been in jail previously and know there are logistical complications that can lead to missed doses (such as court dates, movement between divisions, etc). As mentioned before, there are many complex psychosocial factors involved in deciding if and when it is appropriate to start meds. Many of these patients are homeless and need a more stable living situation "on the outside" before they are ready or willing to take meds. Many are active substance abusers and would benefit from a drug treatment program before starting antiretrovirals. Many have untreated mental illness that would negatively affect their ability to adhere to therapy on their own once released. Many are in jail for a very short stay; their treatment decision can be delayed until released in some cases.
You wrote that some of your patients are mentally ill. What can you do with them to make sure they are adherent?
All patients with significant mental illness by history or by my assessment are given referrals to our mental health services. Unfortunately, these are arguably the most difficult cases to deal with (just as they are on the outside). Sometimes we see an almost miraculous improvement in psychotic symptoms when the patient is started on anti-psychotics by the psychiatrists and, as expected, it makes adherence to antiretroviral treatment much easier. If any detainee is on a psych med, ALL their meds will be given "dose by dose" by the nursing staff (rather than allowing them to keep a small supply of their meds "on person"). This has potential for increasing adherence, but it is not directly observed therapy.
What do you do with people who are still using drugs? Do you even start them on treatment?
Of course, they are not still using drugs once they are in jail (O.K., so there is SOME drug use in jail, but like sex, it's not supposed to be happening). For those who are using drugs on the outside, we individualize treatment decisions. Some of the heroin addicts never miss a dose of their HIV meds on the outside, so we will continue their meds in jail if they wish to receive them. Some are obviously non-compliant, so it is a tougher decision. Most of them request and receive drug detox and may enter drug treatment programs while still in jail. If these patients do not meet treatment criteria to start meds, I almost universally defer treatment and wait to see them after drug rehab (either in jail or at the CORE Center).
What's the best thing about your job?
I am surrounded by dedicated, compassionate, hardworking people who see their work as much more than just a job. We feed off each other's commitment to providing healthcare and beyond to some of the most disenfranchised people in Chicago.
What's the worst thing about your job?
We are perpetually at risk of losing funding for members of our team. A close second is the challenge of the "logistics" involved in providing high quality care in a correctional setting.
What have been your greatest successes in your work? Greatest failures?
The greatest successes all seem to revolve around making a personal connection with a patient who has otherwise been lost or forgotten by "the system," then seeing them thrive.
The biggest failures thus far revolve around the same situation. I wish we could help everyone restore their health and gain control of their lives. Unfortunately, despite our best efforts and intentions, some of the neediest people return to the chaos of drug addiction, homelessness, mental illness and lack of a support network.
What is the biggest challenge you face as a clinician? Would other clinicians give a similar answer?
At this moment in time, my biggest challenge probably revolves around the uncertainty of adequate funding for all of our programs. I am not certain all clinicians would give the same answer, as I deal primarily with uninsured/indigent inner-city population.
What do you think is the biggest problem people with HIV face today?
Globally, the biggest problem is still availability/access to care.
For the most part, what do you think is the biggest risk factor for HIV?
Lack of education.
What single change would you like to see in HIV care? Why? What would it accomplish?
An effective vaccine. While we have had incredible success with the available treatment options, they are obviously out of reach for the vast majority of infected people worldwide. A vaccine could potentially "level the playing field."
What do you provide in terms of education or counsel for a patient who is just diagnosed?
Like all HIV providers, I try to explain the disease process in terms the patient can understand. Once I am comfortable that they grasp the basics such as CD4 and viral load, we discuss why some patients need to begin treatment sooner than others. Psychological support is provided not only from myself, but from our entire team.
Can you detail the jobs of members of your team. What is a typical team? Do you use peer educators in prison?
My team consists of myself, Mr. Harry Przekop (physician assistant), Carl Jones-El (reentry coordinator), Al Pitts (health educator), Michael Cordova (phlebotomy, clinic assistant), as well as a number of dedicated health educators across the entire jail facility. Additionally, we work closely with both the medicine and psychiatry departments since our patients are scattered across the 100-acre campus. We do not routinely use peer educators in the jail.
One piece of advice I give to all newly diagnosed patients is to be extremely cautious with whom they share their diagnosis. Everyone needs support from those around them, but once "it's out there," it cannot ever be taken back. There is still ignorance/stigma, etc. even in our "enlightened" times.
What do you provide in terms of education or counsel for a patient who is about to begin treatment?
Adherence, adherence, adherence. After I finish force-feeding that concept, we go over adherence some more. Once I think they have received the message, we go over it again. It is the first and last thing discussed at every encounter. Of course, I do not practice paternalistic medicine. I give all patients choices (when appropriate) regarding when to start, which drugs, etc. The availability of our Pharm.D., health educators, social workers/case managers, mental health services, etc. are defined.
If you were infected with HIV today, at what T-cell count would you begin treatment? Explain.
This is a very difficult question to answer. While I believe in evidence-based medicine and frequently follow guidelines, I think I would lean towards starting therapy a little sooner than recommended. I would probably not allow my CD4+ count to dip below 400 without starting therapy. This is mostly based on observational experience, but most HIV-related problems begin with a CD4 below 350 or so. I guess I would just feel more comfortable with a little extra "breathing room."
What treatment regimen would you choose if you had to begin treatment today? Explain.
Assuming I was infected with wild-type strain (and not drug-resistant HIV), I would likely elect to use a once-a-day regimen including two nucleosides and a non-nuke. I am no different than most patients in that I would rather not have to remember to take pills twice (or more) a day. Additionally, because I have hyperlipidemia at baseline, and, in general, I would feel a protease-sparing regimen would be safer over the long term for me.
What's the key to a great healthcare provider/patient relationship?
Trust. Many of my patients are extremely distrustful of authority figures. Rather than being viewed as someone who can help them, we are sometimes seen as people trying to control their lives.
What is the source of their distrust?
Many of them have been totally disenfranchised by society, their families, etc. (even before they have an HIV diagnosis). Since they have a lifetime of people NOT helping them or seeming to care about them, when someone finally reaches out to them, it seems almost reflexive to be distrustful at first. What do you do to break through to them? I don't know. I guess I'd like to think being non-judgmental plays a big part.
How do you feel about patients who take a proactive role in their own treatment? Do you have many patients who are proactive? What do they do to take a more active role.
I feel proactive patients are a "double-edged sword." While I love to see people actively seek information about their illness, there is too much "bad" information out there. Further, much of the information my patients receive comes in the form of direct to consumer marketing from the drug companies. Few patients come to me asking about a study from peer-reviewed literature. Instead, they come in asking about an ad they saw on the bus or in a magazine. Properly informed patients are better able to make self-assessments and troubleshoot their own problems. I do not have many proactive patients.
Who was your all-time favorite patient and why?
I don't have a single patient who I would classify as my favorite. I have two patients who are definitely my most challenging due to the complexity of their medical histories. I do look forward to each visit with them, and they are the only patients to whom I have given my pager, cell phone, e-mail and direct office number. I would certainly consider them my friends as well as patients.
What is the most important/memorable/useful thing you have learned from your patients?
I have learned a great deal about the diversity of the human spirit. In many, the will to carry on and live is strong. However, it has been difficult, but important, to realize that there are some people I cannot reach or help.
Tell us about these people. Are there people who refuse to be treated?
Some refuse. Some have substantial mental illness issues. Some are more concerned with non-medical issues like having a place to sleep or food to eat when they get out of jail. Some are addicts who have to deal with their substance use issues first. Some have limited or non-existent support networks to help them on the outside. We do everything our resources allow to try to overcome these and other barriers, but the sheer volume of the problems make it impossible to help everyone.
How do you maintain a positive outlook and avoid burning out?
I bring a sense of humor to the clinic every day. I love my job.
If you weren't a clinician what would you be? Why?
I would probably be a teacher. I love teaching and seeing the look of satisfaction when someone understands something new.
Who would you dedicate this award to if you could?
My late friend Joe Bass.
We'd like our readers to get a sense of you as more than just a clinician. Could you share a little personal information yourself?
I am 33 years old. I am the middle of three boys (no sisters). My mother lives in a suburb of Pittsburgh, Pa., and my father lives in a rural area outside of Chicago, Il. My older brother is a pilot for a corporate charter airline and a successful marathon runner. He lives in Pittsburgh. My younger brother is a partner in the family business of hotel furniture liquidation and resale. He lives in Chicago.
I was a competitive swimmer for 18 years (ages 4-21). I was valedictorian of my high school class. I attended undergraduate school at Tufts University in Boston. After college, I did not enter medical school immediately. Instead. I spent two years working with my dad in our family furniture business in Chicago. Eventually I attended Rush University Medical College in Chicago, followed by internal medicine residency at the University of Pittsburgh Medical Center.
Where did you grow up?
I grew up on a horse farm in Allison Park, Pa. It is a small suburban town about 10 miles north of Pittsburgh. My high school had about 1,000-plus students, and my graduating class was around 260.
What did you want to be when you were a kid?
A doctor. Oh, and I also wanted to be an Olympic swimmer.
What kind of work do/did your parents do?
My father owned a wallpaper-hanging business. By the time I was in college, he left the wallpaper business and took control of my grandparent's family business after my grandfather died: hotel furniture liquidation and resale. My mother was a stay-at-home mom. She had a full-time job keeping me and my two brothers out of trouble.
When did you decide on medical school?
I was pretty sure I would seek medical school training before high school. I've always kind of had a one-track mind about becoming a doctor all my life. I was a biology major in college.
Who were the most influential people in your life, both professionally and personally? Why?
Professionally, the single most influential person has been Dr. John Pottage. He was a faculty member at Rush University Medical Center specializing in Mycology and HIV. When I entered medical school at Rush, he became my mentor. His bedside manner, compassion, patience and positive, hopeful attitude are characteristics I have tried to model throughout my career. Additionally, I think the entire infectious diseases department at Rush/Cook County who trained me during fellowship, made me a more complete doctor and person.
Personally, my family (especially my immediate family, grandmother, aunts and cousins) has been unbelievably supportive throughout my entire education and career. I am forever indebted to them. My late friend Joe was also a huge influence for me. My partner Shane is my biggest supporter and best friend.
What do you do in your spare time?
I enjoy traveling the world. I am trying to rekindle my old reading habits (pleasure books). I like to exercise (although I am guilty of extended lapses from time to time). I like to explore Chicago. I like movies (especially scary ones). I hope to be able to spend more time scuba diving in the future.
Do you have a partner? What is your partner's job?
I have a partner of 5.5 years. His name is Shane. He is currently a psychiatry resident, with one year left in his training. We have no kids, but we have two Siamese cats: Sesame and Cuzco.
Where do you live? What kind of community is it?
We live on the North Side of Chicago. It is an interesting neighborhood. It was traditionally an ethnic Swedish neighborhood, but over the past 10-15 years it has slowly been gentrifying (like many neighborhoods in Chicago). There is also a strong gay presence here. It is about 10 tree-lined blocks from a beautiful beach. Most of the storefronts in the business district are independently owned small businesses, but we also have the ubiquitous Starbucks and Einstein Bagels. Within walking distance are an ethnic Vietnamese neighborhood, a cemetery, a beach, the El and our gym.
If you had any place to live besides where you live now, where would you live?
While my world travels are incomplete, at this point in time, I would also like to live on Phi Phi Don Island in Thailand.
What's the best vacation you ever had?
During my internal medicine residency at the University of Pittsburgh, I used my senior elective month to travel to Thailand for a tropical medicine course. At the end of the month, I took about a week to explore some of Thailand. One of my life's dreams was to learn to scuba dive, and I was encouraged to visit the Phi Phi islands, known for their amazing dive sites. I spent five of the happiest days of my life on those islands. If the natural beauty wasn't enough, the climate, food, people and attitude pulled the last ounces of stress/anger/evil out of my body.
What's the biggest adventure you ever had?
My trip to the Phi Phi Islands. While I have traveled abroad many times before, this was the first time I was doing it alone. It also was in October 2001, just after the 9/11 tragedy. This added to my trepidation, but once there I never felt threatened or unsafe at any time.
What's currently on your bedside table for reading? What book would you say has had the most impact on you?
At my bedside is Guns, Germs, and Steel by Jared Diamond. Most influential book was The Story of B by Daniel Quinn.
What kind of music do you like to listen to? What's album do you listen to the most?
I tend to listen to a variety of music. While my tastes have definitely changed over the years, I still listen to lots of techno/hi-energy music. I also enjoy jazz, classical, international and, of course, '80s hits. I still have not acquired a taste for country music.