A local HIV treatment and prevention clinic combats both old myths and new complacency to drive down a persistent infection rate.
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Thirty-six years ago, scientists gave the AIDS virus a new name, calling it the human immunodeficiency virus, or HIV. It was often lethal, and patients were treated (when they could be) in inpatient acute care hospitals.
Founded in 1990, the AIDS Care Center served a vital role in the Hudson Valley, caring for people with HIV infection. It has transformed from being an inpatient care model to one that is entirely outpatient. It also has a new name, the Ally Care Center, an HIV Treatment and Prevention Primary Care Clinic. The Hawthorne-based center is part of the Westchester Medical Center Health Network (WMCHealth).
Dr. Rebecca Glassman is the Medical Director for the Ally Care Center. She attended medical school and did her internship, residency, and first five years of medical practice in Boston. She and her husband, both Westchester County natives, moved back about 18 months ago with their three young children. She described it as a real homecoming.
While a series of medical breakthroughs have left the general public thinking that HIV is a thing of the past, the reality is that HIV continues to spread at an alarmingly high rate, given all we know. In 2019, 36,801 people received an HIV diagnosis in the United States. From 2015 to 2019, HIV diagnoses decreased only 9% overall in the U.S.
Examiner+ recently spoke to Glassman about the clinic, changes she has seen in caring for people with HIV, and some common public misperceptions.
Examiner+: What led you to specialize in HIV care?
Rebecca Glassman, M.D.: I am truly a primary care physician, not an infectious disease specialist. Traditional internal medicine residencies have a heavy focus on inpatient care. I was interested in in-depth training opportunities to learn about outpatient medicine.
I trained in an inaugural HIV primary care program, where I also learned about gender-affirming care and became proficient in providing gender-affirming hormone treatment. I felt like I found my passion and calling to be able to provide comprehensive primary care for individuals living with HIV.
E+: Tell us more about the evolution and the current focus of the Ally Care Center.
Glassman: The name Ally Care Center was a shift for several reasons. One is that we want to make sure that we are more inclusive of the individuals that we serve. We provide care to approximately 450 patients. AIDS doesn’t capture the majority of our patients who never reach that diagnosis ― so many of our patients are living with HIV and are healthy.
We really want to make the Ally Care Center a primary care clinic for everybody, and the big push for us is to create a very safe and welcoming environment to provide gender-inclusive care to anybody seeking it.
We have several patients who are HIV-negative but have an ongoing risk of acquiring HIV, and we offer them protection with prophylactic medications.
E+: What are some of the major public misperceptions about HIV?
Glassman: When we ask people which body fluids can spread HIV, we often hear saliva, tears, and sweat included. That’s an important misperception that we want to negate, so people know that there is no risk of transmitting through kissing, hugging, touching, or sharing cups with individuals living with HIV.
On the other side of the spectrum, some people don’t think HIV still exists. I think there is a feeling that the rates of HIV have gone down, which they have to a certain extent, but not enough that we have ended the epidemic.
E+: What are we seeing in local demographics of newly acquired new HIV infections?
Glassman: According to 2019 CDC data for Westchester County in 2019, there were 87 new cases of HIV, with a total of 2,336 new cases for New York State.
The leading age range for new infections is among 25-34-year-olds and is primarily concentrated in Black and Latinx men who have sex with men. Those are really the priority populations for screening and education about the benefits of pre-exposure prophylaxis.
E+: What should people know about prophylaxis medications that can be used to prevent infection both before and after they are exposed to the virus?
Glassman: Pre-exposure prophylaxis, or PrEP, is medicine taken to prevent getting HIV and is extraordinarily effective. It’s now approved for three different medications, Truvada, Descovy, and Apretude.
Truvada and Descovy are pills that are taken every day. Apretude is an injectable form of PrEP that was recently released. It’s given every other month by a medical provider, and in my opinion, is incredibly life-changing for individuals to be free of having to take a pill every day.
Post-exposure prophylaxis, or PEP, is taken orally for 28 days after exposure has occurred. In most cases that we see, it is with patients seeking PEP because of sexual assault. They are prescribed medications in the Emergency Room to prevent HIV and we monitor them for the month to come. PEP is very effective and there are very few people who acquire HIV if they have been given PEP within the appropriate timeframe of within 72 hours after exposure.
E+: Part of your work is to educate the public, but you also help educate other healthcare providers, correct?
Glassman: When you see the distribution of new infections and PrEP prescribing, it is very shocking. About 18% of the U.S. population that has an indication for PrEP is currently receiving it, so we are not reaching even close to the number of patients who would benefit from it.
We need to educate primary care doctors to be doing this. It’s not enough to say, ‘I know how to prescribe PrEP,’ they need to ask questions to understand the risk for their patients and not make assumptions. It’s so important to provide an open space when taking a social history from patients. If we assume that a patient who is 50 years old and married means they have a monogamous relationship without any added risk, then we have lost the opportunity to test, educate, and prevent.
And we look at who is receiving a prescription, 42% of people receiving prescriptions for PrEP are White, 11% are Latinx, and 6% are Black, so there’s huge inequity when you look at who needs it and who’s getting it.
E+: Is the discrepancy primary due to education, access, insurance, or discrimination? What are the factors?
Glassman: I think it’s all of those. I think that it’s education, access to routine medical care, and asking questions to identify the risk. I think it’s primarily an issue of accessing medical providers who are going to ask the questions and once asked, take the step forward to say, ‘Do you know about PrEP and do you think it would be of interest to you?’ If it’s not of interest to you, you at least have the knowledge to educate your friends, and if you choose, you know where to access it in the future.
E+: We talked about drugs used to prevent HIV infections, what about one of the newer drugs, CABENUVA, that is used to treat HIV?
Glassman: CABENUVA is used to treat someone who has HIV. It is given in two injections, either monthly or every two months.
The goal is to maintain viral suppression and immune functioning, and it is as effective as our other first-line regimens, but it removes the stress of needing to take a pill every day. For many of our patients, that means being pill-free for the first time in decades.
I think there is still a significant amount of stigma about HIV, and while we try to work very closely with our patients to overcome that, it exists. Many of our patients have unstable housing and so they fear others finding their pills. The ability to be on CAPANUVA is life-changing.
The biggest stipulation before starting this medication is that you have to have viral load suppression and you can’t have any resistance to either component of the medication.
E+: What does viral suppression or undetectable mean in this case?
Glassman: Viral suppression is when the viral load is undetectable or less than 200. There is powerful data to show that if an individual’s viral load is suppressed, they cannot transmit HIV to another sexual partner. We emphasize this to our patients and their partners because it allows them to feel safe engaging again in their social life, their sexual life, and also empowers them to take ownership over their own medical care.
We are working to make this option available to as many patients who qualify. We have had some exciting success with long-term survivors who have struggled with adherence. Once they are suppressed, we get them on CABENUVA with ongoing control. We are seeing them engage in other parts of their lives, like seeking employment and partnerships in a safe way for the first time in years.
E+: What are some of the other care aspects at the Ally Care Center?
Glassman: We are a multi-disciplinary care model that includes dedicated case management and mental health counseling.
Our case managers take care of every single one of our patients; they have their cell phone numbers, they arrange transportation. If patients miss their scheduled visit, the case managers reach out and reschedule them.
For community outreach and education, I work alongside a physician’s assistant and a nurse practitioner, plus our PrEP specialist and peer navigator. We have a wonderful mobile health unit that allows us to do onsite testing and then prescribe for PrEP if appropriate.
E+: When you attend community events, what are some of the health concerns you hear from the public?
Glassman: I think a lot of people are seeking a safe place to enter the medical community and primary care doctors are that door. They are seeking individuals who will be mindful of preferred pronouns and gender preferences and partner preferences. That is what we are seeking to do in our clinic is to keep that door wide open.
We are also amazed by how limited sexual health education is in the community. It doesn’t matter where somebody is in the spectrum of their sexual exploration; we have 15-years old and 75-year-olds who come to us. We have a Jeopardy game, called, “Know Your STI’s” and it’s amazing how much people can learn about sexually transmitted diseases by engaging in this fun and educational game.
E+: Give me an example of one of the questions that gives people an “ah ha” moment.
Glassman: My favorite one is, “What is the most common symptom of an STI?” The answer is, “NO symptoms.” The big take-home is that just because you have no symptoms, it doesn’t mean that you shouldn’t be screened for sexually transmitted infections. So often, patients who come to us are asymptomatic and we want to make sure that everybody gets comprehensive testing at all possible body locations that may be a risk.
Sherrie Dulworth is a lower Hudson Valley freelance writer whose stories range across healthcare, careers, literature, and human interest. She often finds tranquility with her nose in a book or her feet on a hiking trail, but not simultaneously. Check out her blog for fellow bibliophiles at www.curiouscatsread.com, and her website showcasing her other works, www.sherriedulworth.com.
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