HIV, COVID-19, and Telehealth: Where Do We Go From Here, Panel Asks

A panel of experts came together on day 3 of AIDS 2020 to discuss their experiences with telehealth—its benefits and challenges—and the extraordinary impact this care innovation has had on the HIV epidemic during the first few months of the coronavirus disease 2019 (COVID-19) pandemic.

In “Disruptive Innovations to Help End the HIV Epidemic, and the Rise of Telehealth,” moderated by Jeffrey S. Crowley, MPH, the panel discussed not wanting to disrupt the continuum of care for their patients with HIV, those at risk for the virus, and their care teams, as well as proffered advice moving forward in continuing to offer the service, based on their experience with the service thus far.

Crowley, program director of infectious disease initiatives, O’Neill Institute for National and Global Health Law, Georgetown University, was joined on the panel by:

• Christian B. Ramers, MD, MPH, AAHIVS, director of graduate medical education, San Diego State University School of Public Health; assistant medical director for research and Special Populations, Family Health Centers of San Diego
• David Ernesto Munar, president and CEO, Howard Brown Health (HBH)
• Laura Waters, MD, FRCP, HIV/hepatitis lead, NHS Mortimer Market Centre
• Michael Murphree, LCSW, chief executive officer, Medical Advocacy & Outreach (MAO)

During the panel discussion, Crowley and the panelists touched upon a wide range of subjects within telehealth for the HIV care continuum: their experience with the technology; how it has helped or hindered their patients’ access to care; is telehealth here to stay; major barriers to its uptake; and advice for its use going forward.

Experience

Murphree may perhaps be the most experienced with telehealth among the group, having used the technology at MAO since 2012 to reach the mostly rural, minority patient population (76% are black or African American) his organization serves in Alabama. MAO uses its own internal bridge system, with a nurse practitioner on end who collaborate with a nurse on the other end, to offer a wide range of services that include addiction counseling, medical nutrition therapy, and pharmacologic management.

“We have 3 hub sites and 11 Alabama e-Health Satellite Clinics, and we will always have a person working with our recipients directly,” he noted. “We offer a very highly protected environment for our service delivery.”

On the other end of the spectrum is Munar, under whom HBH only launched its telehealth offerings in March in response to COVID-19.

“We mobilized our teams and launched telehealth in about 12 days and made some radical changes to our model of care,” he stated. “We've had to create some protocols for rapid access to our labs for blood draws, but otherwise, we've been able to deliver quite a bit of our service lines through telehealth.”

This almost seamless transition has enabled HBH to continue offering a majority of its full-spectrum services in Chicago, from prevention to sexual health screenings to care for transgender patients, even the provision of in-home HIV and STD testing supplies, to the tune of almost 14,000 telehealth encounters since March. HBH currently provides primary care to 4789 HIV-positive adults, and 1426 have attended at least 1 telehealth session since March.

Access to Care

Whether telehealth has been a boon to HIV care access remains to be seen, with the panelists highlighting that we’re still in the midst of the COVID-19 pandemic, so comparable experience under similar circumstances is not entirely possible at the moment.

“We've certainly seen some real engagement, but whether that's been driven by access to telehealth, versus the general anxiety and fear that people experience around COVID-19,” Waters pondered, “it’s really hard to say. All of our changes happen very quickly.”

What was apparent was the necessity to ensure patients remain engaged.

Ramers especially noted the importance of overcoming the transportation and physical and social distance barriers. “Engaging with care through telehealth has been a real boon to allow us to reach out to patients,” he stated. “The convenience factor really removes those barriers.”

Staying Power

Crowley noted that although the HIV space has used telehealth for quite some time, the COVID-19 pandemic has really raised its profile, and so he asked the panelists if they thought postpandemic times might see it stick around to the same degree. They seemingly agreed that it is not going away, but that the patients always come first in how they will be affected and the technology will continue to evolve according to their needs.

“I think we need to gather as much evidence we can, the benefits and then potential risks, and of course, we have to think about the service users who’ve been scared to come to clinic,” Waters stated. “I think it's been a massive kick up the backside, and I hope we'll end up with a service with much more patient choice.”

Ramers agreed, pointing to the need to continuously innovate telehealth to keep it relevant. “It's a great time for innovation,” he said. “I would just emphasize that if you don't incorporate this into your practice, and you don't adapt, you're going to be left behind. We've just trusted people a lot more, and I think our results have been really good.”

Barriers to Uptake

What, if anything, could prevent the adoption of telehealth among persons with HIV? Again, patients. They were at the forefront of the responses, in that the panelists said we have to listen to their needs, but that they often exceed our expectations in what they are capable of. There needs to be a focus on patient and provider education, the panelists emphasized.

“Most of the folks who are living with HIV, even in rural Alabama and Mississippi, have more resources than we think,” Murphree said. “We’ve just got to understand them better and listen to them.”

Munar echoed Murphree in noting the importance of understanding patients, but that to understand potential telehealth uptake barriers, it’s necessary to take our time. “I am concerned that we need to slow down and do some evaluation and really understand who we’re reaching or not reaching.”

Advice Going Forward

Closing out the session, Crowley asked the panelists each to give one piece of advice for those considering telehealth.

“The power of a hand squeeze and the power of a hug at the right time are really important, and determining when people want and need, that is crucial,” Waters stated.

“We need to adapt to what our patients want,” Ramers said. “I love the idea of letting the patients lead the way and tell you what they want in terms of their risk aversion.”

“I think we all are in agreement here,” Murphree contributed, “that the more options you have that are realistic, the better that retention in the medical care will be.”

“The new workflows should not be disruptive to our patients,” Munar concluded. “I think making sure that we bring together teams that are comprehensive.”