Paul's clinic sits in a neighborhood that was once run-down and crime-ridden, but has since been partly gentrified. Now, the clinic draws a diverse range of HIV-positive people from throughout the surrounding area, including people living in single-room occupancy hotels and residents from Harlem and the Bronx. Many of Paul's 90 patients are immigrants hailing from Puerto Rico, Mexico, the Dominican Republic, Haiti, South America and Africa.
Paul's work stretches far beyond simply providing HIV treatment. He works tirelessly to improve his patients' quality of life, by helping his department coordinate insurance issues, housing assistance, mental health services, hepatitis C care and treatment for people with drug addictions. He has also reached beyond his clinic's walls to develop one of the first efforts to take HIV testing straight into the neighborhood, by offering rapid HIV tests (using a finger stick and producing a result in about 40 minutes) from specially equipped vans and provided technical assistance to the New York City Department of Health in implementing these programs. Realizing that many of his patients may be poor or have little or no social support, Paul's team gives time and thought to training counselors for this project. They provide HIV counseling in the van, and if a person needs a confirmatory HIV test (which is ordered when a rapid test comes back positive, and can take as much as a week to analyze), his staff makes sure to follow up with that person when the new test results are available, so that nobody gets lost in the shuffle.
Though Paul is the one receiving an HIV Leadership Award, in the true form of a humble neighborhood hero, he is quick to deflect the praise onto his dedicated staff. "From my first day at [the clinic], they have demonstrated a commitment and compassion to their patients," he says. "They continue to set the bar high for me to aspire."
How long have you been practicing?
I have been a physician assistant (PA) since 1999 and have been working in HIV care since 2001.
What's the best thing about your job?
For me, the best thing is working with the patients. The core reason that I studied to be a P.A. was that I wanted to feel connected to my job and in some small way make a difference. Treating, educating and helping my patients live with HIV is a job I am honored to be able to perform. That being said, I do also enjoy the development process for clinical programs. I feel that my project management experience in my previous career as a consulting meteorologist has helped me to move clinical programs forward (with the help of very talented and dedicated staff).
What's the worst thing about your job?
There is just not enough time to get everything done. I am sure I am not the only one who feels this way.
What have been your greatest successes?
With the support of a progressive Board of Directors and Administration, and with the help of a dedicated and talented group of physicians, nurses, case managers, social workers and support staff, I have been able to work collaboratively to help create several programs including:
What do you think is the biggest problem people with HIV face?
I can't provide only one answer to this question!
Of course, the recent disclosure of a potentially short-progressing, multi-drug resistant strain of HIV is of concern and I await the results of further investigation into its prevalence. This development highlights the need for new drugs to treat HIV including additional drugs from existing classes and new classes of drugs. Without a preventative and effective therapeutic vaccine, continued drug development is essential for people with HIV as they move into their second decade of combination therapy. This development also emphasizes the need for effective HIV prevention programs for both people who are HIV negative and those who are HIV positive. The ABC method (abstinence, be faithful, use condoms) can work, especially when its message is tailored to the specific populations being targeted. Furthermore, condoms used consistently and correctly greatly reduce the risk for transmitting HIV and other sexually transmitted diseases.
An immediate problem is the lack of adequate federal funding for prevention and treatment programs in the United States. President Bush has recommended only a very small increase in funding for the Ryan White Care Act, a program that has been essentially flat funded for the past three years. A static funding plan coupled with double-digit percentage increases in the costs of health care in those same years results in a significant net reduction in the availability of funds for health care services. When you add in the proposed cuts to Medicaid, and the increases in HIV infection among women and communities of color, a crisis looms for people living with HIV/AIDS in the United States.
This squeeze on the availability of desperately needed funding for HIV care has created an adversarial relationship between different areas of the country vying for an ever-shrinking pool of real funds for HIV care. I hope that people with HIV and their caregivers from around the country can unite and with one voice let Washington hear that adequate domestic funding does the most to reduce to spread of HIV. HIV-infected people who receive effective HIV treatment live healthier, longer, more productive lives, require fewer hospitalizations and reduce the spread of HIV.
What single change would you like to see in HIV care?
Of course, a cure is the ultimate goal. However, an effective preventative vaccine and/or therapeutic vaccine to slow or halt the progression of the disease would be a monumental development for people with HIV. I continually look at updates on vaccine clinical trial data for promising candidates.
Does the William F. Ryan Community health center see mostly poor patients with multiple issues? If so, what are the programs that you provide that may be different then in a private doctor's office? What are the particular needs of this clientele?
Many of our patients are dealing with many other health and social issues beyond their HIV infections. These include mental illness, active drug use, homelessness or unstable housing, child-care issues, disability, etc. We have a full-service HIV support service department including case management, mental health, harm reduction services and nutrition services. We are also funded to provide intensive medical case management in our Maintenance In Care program. Patients most at risk of dropping out of care are connected to a Care Technician who in conjunction with the medical team helps the patient to remain adherent to treatment and keeping their appointments. We also run many support groups in both English and Spanish.
What percentage of your clients are on ADAP? Medicaid?
In 2004, approximately 35% of our patients were on ADAP (AIDS Drug Assistance Program) and 55% on Medicaid, with less than 10% are on private insurance.
What are the particular issues of this population?
About 50% of our patients have incomes at or below the federal poverty line, with another approximately 20% at 200% of the federal poverty level. These are patients with little or no resources to pay for medical services.
Do you have clients who are illegal immigrants? Does your clinic provide care for them?
Ryan treats all patients without regard to their ability to pay. We treat many documented and undocumented immigrants at Ryan and, where possible, connect them to medical benefits. We have patients from Haiti, Dominican Republic, Jamaica, Mexico as well as other countries of Africa, South America and Eastern Europe. Many undocumented immigrants work in low-paying service jobs in restaurants, retail and lower skilled labor and none of these jobs provide medical benefits. Without the state ADAP program, these people would not be able to access medical treatment for their HIV. This program is literally a lifesaver for them and an effective HIV prevention tool for the community because people in HIV care have a lower incidence of HIV transmission than untreated people.
What do you provide in terms of education or counsel for a patient who is just diagnosed?
An article I wrote for ACRIA in the Winter 2004/2005 issue addresses this.
What about to patients who are about to begin treatment?
I review the current drug regimens and guidelines and discuss possible medication side effects and dosing requirements. Every discussion includes adherence requirements and resistance development. All patients new to therapy first meet our treatment adherence staff to provide more information, support and, if needed, reminder devices. I like to have as many supports as possible in place before starting HAART.
Who would you dedicate this award to if you could?
I would dedicate this award to the staff of the William F. Ryan Community Health Center. From my first day at Ryan, they have demonstrated a remarkable commitment and compassion to their patients. They continue to set the bar high for me to aspire. Many of our patients are dealing with homelessness or unstable housing, mental illness, substance use, language and cultural barriers and (still) stigma and discrimination due to their HIV status. These issues pose great challenges in maintaining a connection to medical care. The Ryan staff work every day to overcome these barriers and improve the health of our patients.
We'd like our readers to get a sense of you as more than just a clinician by sharing a little personal information. Where did you grow up?
Ridgefield, New Jersey, just across the Hudson River from New York City.
What did you want to be when you were a kid?
I remember wanting to be an astronaut. I was six years old when the Apollo crew landed on the moon; pretty amazing stuff for a kid. That is what initially sparked my interest in science and the atmosphere.
What kind of work did your parents do?
My mother was a stay-at-home mom (they had more of those back then!). My father worked as a bookbinder in New York City. Typical blue-collar suburban upbringing.
How did you come to be a physician assistant?
My previous career was as a meteorologist working for environmental consulting firms. I performed air quality dispersion analyses and Clean Air Act compliance work for industrial clients. After working in that field for 12 years, I became dissatisfied with a technical career that had no human component. I felt I wanted a career in the medical field, and if possible, specifically in HIV care. Over a period of a few years, I went back to school at night to gain biology and health credits and volunteered in health care settings and eventually applied and was accepted to the Philadelphia University P.A. program. So I quit my job, sold my home and moved to Philadelphia to go back to school at 33.
What made you decide to go into HIV care?
In the mid-'90s, people with HIV were (and still are) those who were in the most need. Combination therapy was just starting to take its current form and there was, and to a certain extent still is, an enormous amount of stigma regarding HIV infection. Also, HIV treatment guidance is constantly changing and it is a very dynamic branch of medicine that I was drawn to. I thought if I was going to change my career it should to something that challenged me and could have a positive impact.
Do you have a partner? Kids?
My partner, David, is a financial analyst for a large multinational corporation and he is very understanding of my long hours at clinic. We do not have children, but my eight-year old niece and nephew are a central part of our lives. They love visiting New York City and think the subway is the "coolest thing."
Where do you live? What kind of community is it?
We live in suburban New Jersey just outside of New York City. It is where I grew up and we both love combining the proximity to New York City and its cultural resources with the suburban aspect of our lives
If you could live anyplace else where would it be?
What's the biggest adventure you ever had?
I went skydiving a few times while in college -- it was an amazing experience. I won't be repeating that in the future, I feel much more mortal now.
Before you were nominated, did you know about The Body or The Body Pro? If so, what were your impressions?
I was very aware of The Body Pro previously. I find it to be a great resource that has helped me get up-to-date concise information on HIV treatment. And I am I not saying this because of the award! I log on at least weekly and circulate updates to the clinical staff as part of Ryan's continuing education program.