There have been lots of news stories about what risk the coronavirus pandemic means for people living with HIV. But few stories have explored what it means to be living with HIV and needing to get into care, with hospitals and clinics stretched to capacity as infectious disease medical providers diagnose, treat, and care for those suffering from COVID-19. This is a challenge, especially for people newly diagnosed with HIV, who may be more afraid and uncertain in a time like this.
To find out more, our correspondent Terri Wilder, M.S.W., spoke to Randall McDavid, M.S., NP-C, FNP-BC, AAHIVS, director of medical services with the Colorado Health Network in Denver. Colorado Health Network is a statewide organization that currently serves over 5,000 individuals living with HIV, by providing a broad spectrum of holistic support services, including medical and oral health care, case management, mental health and substance abuse counseling, nutrition services, and financial assistance.
This interview was recorded on March 27.
Terri Wilder: As of today, the United States has the highest number of confirmed COVID-19 cases in the world. Can you talk about how COVID-19 has impacted your community in Denver, Colorado?
Randall McDavid: From what I understand today—you know, everything’s changing by the hour, of course, across the whole nation and in the world—but here in Colorado, I think we’re the 13th state, with the number of COVID-19 cases. And I think we’re around 600 positive cases right now in the state of Colorado.
But, you know, to be honest with you, I know here in Colorado we are definitely a week behind, as the labs that we are using—we have to send our labs out to Arizona; and it’s taking six days to get the results back.
What most people may not know is that the testing, actually, the sample has to be frozen. And you could do a nasopharyngeal swab or an oral pharyngeal swab. But both of those have to be frozen and then the sample sent out; and it takes about six days to get it back.
How it’s impacted our community, of course—I’m sure it’s the same as across everywhere—we were officially put on a statewide lockdown from our governor, [Jared] Polis, as of yesterday. And it has definitely made people a little stir crazy being at home, for sure.
How the Coronavirus Has Affected Standard HIV Care: Virtual Visits, Reduced Hours, Symptom Screenings
TW: You are an HIV medical provider. I’d like to talk about how this pandemic has impacted your practice, particularly around any of your patients who have been newly diagnosed with HIV. Can you talk about, first of all, how it’s impacted your practice, in general? What has your organization done? Are you still seeing patients? Are you doing more telemedicine? Telehealth?
RM: It has definitely changed how we operate, on all aspects. We have had to quickly change how we deliver health care at Colorado Health Network. We were implementing—or, we actually are implementing—telemedicine this year, where we have virtual visits. We have purchased Medpods [at] our main Denver location here, but we have five other rural locations in the state, where we provide case management services. And we were expanding to provide medical care out to those areas. So, this all got a little bit fast-forwarded.
Traditionally, I’m sure that most health care providers know that insurance companies would not reimburse us if we billed for telehealth medicine. The insurances have definitely lifted that, and we are now able to bill for our time that we spend on the phone with a patient for telephone services. So, I’m very grateful that that has changed.
For the newly diagnosed patients, or just any of our patients, in general, our operations have changed to 20 hours a week. We are open from 10 a.m. to 2 p.m. Monday through Friday now. And anyone who is entering the building, if they don’t already have an appointment, everyone is screened who comes into our building. And they’re asked if they have traveled internationally in the last 15 days. And then, they’re asked if they have a fever of over 100.4, cough, shortness of breath. We are now asking if they’re having difficulty smelling or tasting their food, as part of our symptomology questions.
If they answer yes to any of those things, we ask them to not come into the building. And, again, these are for people who are just walking into the building.
If the clinic patients come in—they’ve already called us and let us know about their symptoms and possibility of being exposed to COVID, or they feel like they have symptoms of COVID-19—then as soon as they come to the building we let the people know up front who’s coming in, who has an appointment. And they immediately get a mask, and they’re sent down to the clinic. Because our clinic is in the basement.
Caring for People Recently Diagnosed With HIV During the COVID-19 Pandemic
TW: Let’s talk about folks who you have diagnosed recently with HIV. I’m just curious as [to] how that has impacted that particular patient population. You know, it’s a time of extreme change in a person’s life. They’ve gotten new information, they are now being asked to change things in their life. Can you talk about how COVID-19 has impacted, for example, educating your newly diagnosed patients about their new diagnosis? You know, talking about: What is HIV? What are the medications I’d like for you to start taking? How often you’ll need to do labs—that kind of thing.
RM: All the standard education that I give to newly diagnosed patients is the same during COVID-19, with an additional stress that has been added to the patients, as they already probably know [about their HIV status] before they come in. One of the most common themes, or worry themes, that I get from patients is, “I’m going to die.”
I love when they come in, because I’m able to tell them now, with the new therapies that we have available, they’re going to live just as long as someone who is HIV negative. But, now with COVID-19 added on top of that, it adds another layer of stress with those patients—especially when their CD4 count is low.
Recently, I had a 20-year-old Black male who was diagnosed with HIV, and his CD4 count at the beginning was 231. And so, he had to have some education about protecting himself more [since people with a weakened immune system are at greater risk for severe COVID-19].
The American Academy of HIV Medicine has been great in providing some guidelines for ambulatory HIV specialty care during the COVID-19 pandemic. One thing that they suggest, and we have implemented it here in my clinic, is to outreach to people with CD4 counts of less than 500, just so we can offer phone visits to provide education, reassurance, and assess the need for prescription refills.
One thing that I’m doing for my newly diagnosed patients that I traditionally don’t do is, I send a 90-day supply [of their HIV medications] in hopes that the insurance company will approve that. And, you know, that’s just to prevent the possibility of being exposed to COVID-19—it prevents [extra] visits out of the home and into the public. So it’s one thing that we’re trying to do from a public health standpoint at the clinic, as well.
Helping People With HIV Manage Mental Health and Substance Use in the Coronavirus Era
TW: Your patients who are newly diagnosed are receiving this information about having HIV during a pandemic about another virus. Are these people coping differently during COVID-19, in terms of emotionally, versus maybe a patient that you newly diagnosed, let’s say, the end of last year? Are you seeing any different emotional reactions, or intensity of reactions?
RM: Definitely. You know, when we’re actually calling our patients and checking in with them, the most common thing I’m getting is, “I’m not sleeping well,” [and] “I’m using more” if they’re having any addictions to substances. Their anxiety is much higher. And they’re asking for medications. The most common request I’m getting is Xanax (alprazolam, an anti-anxiety medication known as a benzodiazepine).
I try to stay away from the benzodiazepines. One, they’re a controlled substance. There’s just more regulation with those medications. And, two, it also can worsen, or actually cause, depression. And I know some of my patients are using alcohol to self-medicate for anxiety. And those two together just makes me really nervous.
So I typically offer something like propranolol, which is traditionally used as an antihypertensive agent for elevated blood pressure; but it also could be used for situational anxiety. And then I’ve been using hydroxyzine, which is an antihistamine, but it works well for acute anxiety as well.
But definitely, mental health has always been something to highlight and to bring awareness to anybody’s practice who is treating HIV; and definitely, COVID-19 has seemed to increase this. As everyone knows in the state of Colorado, marijuana is legal here. And when the governor announced the other day that the state was going to be on lockdown, he said that dispensaries and places who sell alcohol were going to be closed, as well. And you should have seen [it], the lines were just wrapped around the buildings for people to get stocked up.
But probably a couple of hours later, because media was there, the governor quickly changed his mind. And so people can still access those, as it’s considered an essential service.
HIV Care Providers Are Providing More Remote Care Due to Coronavirus Concerns
TW: I want to go back to something that you were just talking about, in terms of mental health, substance use disorder services. How has COVID-19 impacted your patients’ ability to receive mental health, substance use, or other social services? Is that more challenging for them now? I’m just thinking about, you guys are open 10 a.m. to 2 p.m. I’m assuming some of that stuff can be accessed via telephone. But what if somebody needs buprenorphine, methadone, etc.?
RM: Here at Colorado Health Network, we have behavioral health services. And, actually, the access is better, to be honest with you. Our behavioral health clinicians are working remotely from their homes, and they’re able to see patients virtually. Obviously, the challenge would be if—some of our patients are homeless, so some of them don’t have access to a mobile device or to a computer where they could access this service. But they do have the option that they can come in and access those services.
We don’t offer, here at Colorado Health Network, any medical-assisted treatment, as far as buprenorphine or methadone. But from what I’m understanding from our public health here in Denver is that they are still able to access those services from other organizations.
TW: I wanted to ask about how COVID-19 has impacted your ability to kind of manage physical symptoms related to HIV, or side effects for new medications for your newly diagnosed patients. Have you had to do anything differently around that? Have there been any challenges, just because of the situation of people being encouraged to stay home?
RM: I think what was confusing for me—because I did have a patient recently who was diagnosed on Feb. 28, who had acute HIV symptoms, which is night sweats, fever, sore throat, swollen lymph nodes, rash on the face and the chest. It was definitely textbook acute HIV. What’s confusing, you know, is this patient’s like, you know, “Could I have COVID-19?”
And so it’s, like, well, on Feb. 28, the symptoms were kind of similar. Obviously, the patient with acute HIV only would not be having a cough or shortness of breath with those symptoms. So that’s kind of a couple of things that you can do to differentiate between the two.
TW: How has COVID-19 impacted your ability to get labs done for your newly diagnosed patients? You know, when folks are newly diagnosed, then there’s this whole buffet of labs that you want to do at the beginning. Has the situation impacted that? Are you still able to get all the labs drawn? Is it taking longer to get the lab results back? Any impact on labs?
RM: Actually, the labs are coming back even quicker, because there’s not as many labs being processed or ordered at this time, because a lot of clinics are closed and they’ve reduced their hours, as well. And I am in close contact with their management team in the area. And they said that most of their clients have closed their clinics.
As far as the testing, we do offer two different ways that people could get testing. They can go to a freestanding LabCorp and I’ll fax the order, since it’s closer to their home. Or, while they’re here in the office, we go ahead and do it here. Because we limit people here that are in our lobby, or in this building. So we can assure the patient that everything’s been wiped down and everything’s clean. We’re as prepared as we can be for the situation.
Now, as far as if the patient decides to go to a freestanding lab, the freestanding lab does not do the STI swabs—meaning, checking for gonorrhea and chlamydia in the throat or the rectum or, if the provider chooses, to do the vaginal swab; they do not do those. So, if they do choose to go to a freestanding lab, we have to do the swabs here.
So, honestly, when I’ve positioned and offered both of those options, the patients are still choosing, because they’re already in here, just to get everything done at once.
Sex and Coronavirus: Hookups, HIV Transmission Risk, and PrEP
RM: So, what’s happening here—and I can only speak to what’s happening here in Colorado—is that Grindr, traditionally if you’re using the free version, it has a very small range for how many people you can view around you. Since COVID-19, Grindr has opened that up and extended it, where the people can actually see more people around them. And supposedly that’s supposed to create more conversation and things.
But from what I’m hearing from my patients and the community, people are still hooking up with this app. And here in Denver, no one is seeing new PrEP patients except my clinic. So, it just makes me a little concerned. I hope we don’t end up with another public health crisis once COVID-19 is over. [Editor's note: Several providers in the Denver area reached out to McDavid after this interview published to say they are still offering PrEP to people who are interested/eligible.]
TW: Why are other clinics or organizations not seeing new PrEP patients?
RM: I think it’s—you know, people are just trying to limit the traffic that’s coming into their clinics to prevent the spread of COVID-19. And I ask myself: Why are people still hooking up? And I think it’s, you know, people kind of crave, and want to go after, something that they can’t have.
TW: That’s—that’s so interesting, that other organizations are not providing an essential service to the community, in order to limit the number of people coming in. I mean, you wouldn’t tell that to somebody who needs medication for [heart disease], you know?
TW: Is that malpractice?
RM: Well, in our clinic we’ve limited our service to urgent and emergent needs only. And me, as a medical director, I decided that, for the organization, that this is considered an urgent and emergent need. If we can’t change people’s behaviors, we’re not here to stigmatize them; we’re here to just provide care for them. And if they’re still hooking up, I feel like we still need to offer that option for those patients to protect them from getting a lifelong illness like HIV.
And, definitely, one thing is for certain: A lot of people are anxious. They’re cooped up and they’re horny, as the quarantine days are long. But I’ve always prided myself on not providing judgmental care. So I’m not here to judge people. But I’m just here to take care of them. And I want to help decrease that public health risk.
U=U and Staying on HIV Treatment as Coronavirus Spreads
TW: I have one more question about taking care of folks who you’ve recently diagnosed with HIV. What is the conversation now around U=U [unedetectable equals untransmittable] and getting your viral load undetectable during a time that we may not see each other that often? Has that message had to be tweaked a little bit?
RM: Actually, you know, it’s the same. It’s still shocking to me, even for my new diagnoses and for my established patients, too, who still don’t know about U=U. I don’t feel like, as a country, we have done a great job of getting that message of undetectable equals untransmittable. And remember, as a world, we decided that U=U. And the World Health Organization standards are a viral load of less than 200, and you’re considered undetectable.
Many of our lab assays show less than 20 is undetectable. That’s great. But, as you know, when you look at labs, anything that’s above this 20 is in bold. And patients now have access to all these portals. And when they see that bold, they think that they have a detectable viral load. But I am always happy to let them know that if you are less than 200, you are undetectable, and you will not transmit this virus sexually.
And this message is no different with my newly diagnosed patients now. I don’t think that that’s any different in the age of COVID-19.
What I do think is interesting is that these new integrase inhibitors are super-potent. And they get that viral load down very quickly. And the integrase inhibitors are a recommendation for an initial regimen for newly diagnosed patients. It’s because we want that viral load down, as the patient becomes a less public health risk.
For example, my patient who was just newly diagnosed that I talked about, [the] 20-year-old Black male; his beginning viral load was 37,700. And I put him on a new two-drug regimen (dolutegravir/lamivudine) that is recommended in the DHHS [Department of Health and Human Services] guidelines as a recommendation for most people living with HIV. And within two weeks, I checked his viral load. Typically, just so you know, when I have someone who’s newly diagnosed, I have them come back [in] six weeks and I recheck their viral load. But these new integrase inhibitors are so potent, and his viral load was only 37,700, that I figured in a couple of weeks, he’d be undetectable.
He certainly was, just in two weeks.
TW: Great. Well, thank you so much for talking with me today. And thank you for your service. I don’t think we are sharing our appreciation enough for essential workers like health care providers. So thank you for continuing to provide care for your patients and giving the service that you can during this pandemic.
RM: Thank you so much. I really appreciate that. And if I may say, for any providers who are listening today, I just want to reach out to you and give thanks to you for being an important part of the HIV community. Hang in there together, and let’s stay safe and healthy, and continue to do the work that we’re doing.