The Desert Sun
When celebrated author and alternative medicine advocate Deepak Chopra visited Palm Springs in early February, he had an epiphany. Invited to be a featured speaker in the Palm Springs Speaks lecture series, he visited Desert AIDS Project before his event that evening. While touring the campus Chopra realized he was seeing the real-life manifestation of what he’d been advocating for decades.
“For 35 years I’ve talked about health and well-being, a holistic approach, integrative approach — this is it,” Chopra said in a video interview with D.A.P. CEO and President David Brinkman and Chief Medical Officer David Morris. In the soft-spoken yet authoritative voice he’s known for, Chopra described an “amazing experience” exploring D.A.P.’s housing complex; sexual health clinic; acupuncture, yoga and meditation services; and more.
“Now I realize if you have enough love, compassion, joy, if you’re grateful, then abundance follows,” he added. “This is really a good example of abundance consciousness. I hope that everywhere people in the world will be inspired by the Desert AIDS Project.”
Chopra’s optimism that holistic health care can be globally beneficial is shared by many in the positions to implement it. Increasingly, D.A.P. and other organizations that traditionally have brought a whole-person approach to serving clients who are HIV-positive are applying their hard-won victories and lessons learned to primary care patients.
Since it was founded 40 years ago, Chase Brexton Health Care in Baltimore, Md., has seen a dramatic change in patient makeup. In the early days of the AIDS epidemic, every patient sought HIV care. Now only about 10 percent of its 30,000-plus patients are HIV-positive, said Dr. Sebastian Ruhs, director for infectious diseases. Primary care services were added for adults with HIV in 1988, then extended to all adults in 1995. In 1999, Chase Brexton became a federally qualified health center.
Whitman-Walker Health in Washington, D.C., made the shift about 11 years ago when what had been an HIV care facility joined forces with a community health center. Though people with HIV still account for a third of the patient population, the melding of services was a natural step in the organization’s growth, according to Dr. Sarah Henn, director of health-care operations. She recalled that providers would treat patients who had developed side effects from HIV medications, instead of referring them to a primary care clinic. “You want to treat the whole person,” she added.
And then there was the federal funding concern. “At the same time, we were realizing that our Ryan White funding was decreasing,” Henn said. “We couldn’t support ourselves as a Ryan White clinic. We had to become a modern health center that is sustainable.”
Reaction from the LGBTQ community to these organizations’ new emphasis on primary care generally has been supportive. It “helped to decrease stigma,” Henn said about the change. “That has made patients feel more accepted.”
Ruhs agreed. “Coming here, being seen here, getting a letter from here does not have stigma anymore,” he said. “We’re offering everything to everybody.”
Well-established in larger cities, this practice has a growing footprint in the Coachella Valley. In February, D.A.P. announced it would extend its varied services to more residents in need who may not have HIV, and would take on a $35 million expansion of its Palm Springs campus to accommodate them. Eisenhower Health and Borrego Health also all have embraced a more comprehensive approach to primary care, buoyed by varying degrees of experience with people living longer with HIV and grappling with health issues related to aging.
Aging with HIV
“At Eisenhower, we have a slightly different perspective of how to approach primary care and HIV,” said Dr. Ken Lichtenstein, an infectious disease specialist with 35 years of HIV care experience. “For a while it was, and this was the trend in the nation, ‘Gee, people are doing better with HIV, so you don’t need specialists anymore. You can now have primary care providers doing this and they can handle it just fine.’ As it turns out, it’s probably the other way around. Our philosophy is you need HIV specialists who are now having to do primary care for their patients.”
The Eisenhower staff providing care to people with HIV includes board-certified infectious disease specialists and primary care physicians who’ve elected to specialize in it by taking the American Academy of HIV Medicine boards, Lichtenstein said. He estimates that 82 percent of patients seeking HIV care, roughly 1,300 to 1,500 people, get it through Eisenhower’s Rimrock clinic in Palm Springs. It’s among the larger of Eisenhower’s 40 or so health centers on its main hospital campus in Rancho Mirage and elsewhere in the valley. Lichtenstein, who joined Eisenhower in July 2015, primarily works at Rimrock.
Many patients who have HIV are living to a full life expectancy, and that presents a different set of challenges, according to Lichtenstein. “We’re seeing a lot of the diseases of aging which are occurring with increasing frequency,” he said. “Let’s say the incidence is higher at the same age in people who are HIV-infected versus those who are not HIV-infected.”
One of the main reasons for this is the high amount of inflammation that HIV causes in the body. Lichtenstein refers to inflammation as “the driving force in the diseases of aging.” For example, HIV clients may be affected by cardiovascular disease, osteoporosis, frailty and non-AIDS-related cancers sooner than their peers who don’t have HIV would be, he said.
Treating both HIV and diseases of aging also can get complicated, as the anti-retroviral drugs for HIV don’t always interact well with prescription and over-the-counter drugs for other conditions. St. John’s Wart and grapefruit juice, as examples, can prevent anti-retroviral drugs from being absorbed, Lichtenstein said. Also, statins taken to reduce cardiovascular disease react with some classes of anti-retroviral drugs in a way that boosts the toxicity of statins. Adjusting dosage is one of several issues which Lichtenstein said require a physician who can provide more than knowledge about internal medicine and an anti-retroviral prescription.
Attuned to patients’ needs
The insights gained from decades of working with people affected by the AIDS epidemic “absolutely” inform primary care practices, Lichtenstein said. “Probably one of the things that I felt strongly about is that all of those people who have died of AIDS did not die in vain, because of what general medicine has learned from this population,” he said.
The development of Hepatitis C drugs is one such medical advancement. Patterned after anti-retroviral drugs, Hepatitis C drugs have a 99 percent cure rate in eight to 12 weeks, Lichtenstein said. Desert AIDS Project officials cite that 200 of their clients were cured with the new drugs during the past year.
Another lesson from HIV care points back to inflammation and its effect on general health. For example, more physicians now understand that inflammation is a key factor in health challenges around obesity. “It turns out that fat tissue is the second most inflammatory tissue [after lymphatic tissue] in the body,” Lichtenstein said. When people lose weight through diet and exercise, measurable biomarkers of inflammation go down. “Does this have an application to the general population? You bet it does,” he added. “We learned this because of the chronic information associated with HIV.”
High levels of inflammation also are a factor in recurrent sexually transmitted inflections like syphilis, according to Lichtenstein. Six months to a year ago, Eisenhower Health started a sexual health clinic that addresses STIs; HIV prevention through pre-exposure prophylaxis (PrEP) for HIV-negative people engaged in high-risk sexual practices; and post-exposure prophylaxis (PEP) treatment as prevention for HIV-positive who engage in high-risk sex. The latter are asked to visit the clinic every three months.
Eisenhower has made a concerted effort to serve the whole person in other ways, including the recent addition of psychiatrist Dr. John Roberts. Bringing in a social worker and dermatological and urological services also are being considered, Lichtenstein said. And there are plans to attach a pharmacy to the Rimrock facility for patients’ convenience.
“We’d like to have a nationally recognized HIV program,” Lichtenstein said. “Part of it has to do with having a lot of additional things.”
With 22 clinics serving nearly 180,000 people across the valley and Southern California, Borrego Health also offers a smorgasbord of services. They range from dental, behavioral health and women’s health services to HIV/AIDS, transgender health, trans pediatrics and PrEP/PEP specialty clinics.
Before Dr. Clayton Barbour joined Borrego in 2011, it was predominantly a primary care organization with about seven clinics. An internist who provided HIV and primary care at D.A.P. for 17 years prior, Barbour was drawn to Borrego’s philosophy of identifying a community’s health needs and establishing a clinic there to address them. “We’re trying to go where the people live,” he said.
Other programs and services that are in the works include infusion therapy, and Barbour would like to provide more direct care such as an oncology program and indirect services like re-employment help. Many of these ideas stem from experience caring for HIV-infected patients.
“Dealing with HIV, you’re more attuned to patients’ personal lives,” Barbour said. “People in general are not very comfortable discussing sexual issues. Physicians with HIV care experience are more in tune to picking up clues in what people say and what they don’t say,” which is helpful in recognizing Post Traumatic Stress Disorder, mental health needs and other concerns.
A full spectrum of care
When it comes to integrating a patient’s physical, emotional and mental health with basic lifestyle amenities and overall well-being, Desert AIDS Project has created a unique health-care model in the valley. Unlike Eisenhower Health and Borrego, D.A.P. started as an AIDS organization 34 years ago in Palm Springs. Over the years its primary care services and programs evolved to meet its HIV clients’ changing needs. The multimillion-dollar campus expansion is expected to accommodate recent and projected growth. In 2015 alone, the number of clients D.A.P. serves increased by 65 percent, chief development officer Darrell Tucci said.
With more than 200 staff and 400 volunteers, D.A.P. currently provides care to 4,500 clients living and aging with HIV. It reaches across 11,000 square miles of California. The new expansion will allow D.A.P. to extend primary care to residents who are living in poverty and/or are underinsured. Ultimately, it will have a capacity to serve 10,000 people. Beyond that, D.A.P. has a network of resources for referrals.
Expected to be completed in 2020 or 2021, the reconfigured D.A.P. campus will continue to offer dental, behavioral and mental health services; nutritional and social support; jobs and substance abuse counseling; and transportation — more than medications. The multitude of services will be accessible to primary-care patients who qualify, irrespective of HIV status or sexual orientation.
Something else that distinguishes D.A.P. from Eisenhower, Borrego and many AIDS organizations offering primary care in urban areas is its centralized location. “It’s done all under one roof and all on one campus,” Brinkman said. “When somebody travels to receive care here, they can get all of their needs met at one time.”
That’s reinforced by a centralized data base of electronic health records that are shared among caregivers, according to Brinkman. An example he recently gave involved a patient revealing a housing need during a visit to the dental clinic, which prompted the dentist to alert a D.A.P. case manager to help resolve the problem — mitigating any negative impact to patient health because they all were on the same campus and the problem could be handled in a timely manner.
“We want to leverage what we’ve learned works and bring it to more people,” Brinkman said. “We have proof; we have it scientifically in our data, but we also have testimonials [among the] 4,500 people we’re caring for.”
This more comprehensive approach to health care comes with a hefty price tag. During his interview with Deepak Chopra, Brinkman said D.A.P. currently brings in about $38 million a year to care for its existing clients. Expanding its campus to provide services to more people is estimated to cost $35 million. All of the $12 million that has been raised so far — except for a $3 million public gift from Tenet Healthcare Corp., parent company of Desert Regional Medical Center — came from private donations, Brinkman said. A capital campaign is underway to raise the $20 million balance.
While advances in HIV medications cannot be denied in relieving what was once a short-term death sentence, many health-care providers agree that investing in a full spectrum of care also pays off for patients.
“We care for people who have been diagnosed with HIV since the late ’70s, and against all odds they’re here today,” Brinkman said. “They’ve been to more funerals than they’ve been to weddings in their lifetime. Yet today they have purpose in life, they have the ability to contribute back to life. They have lived beyond what any scientist or physician said they could, and part of that is treating the whole person in a holistic way.”