How do you provide care for a nearly unreachable population?
Sandra A. Springer, MD has always known addiction and HIV care need to be integrated to provide the best care. Unfortunately, those facing the most barriers are “always forgotten,” according to Springer. Poverty, housing instability, justice involvement, racial stigmatization, and lack of transportation make it difficult for providers to reach these populations in need of care.
“If we don’t figure out how to reach this population and bring these evidence-based treatment and prevention services to them, we’re not going to make a dent, and deaths are going to continue,” said Springer.
On June 14, Springer received the Avant-Garde Award from the National Institute on Drug Abuse, a branch of the National Institutes of Health, for research on HIV prevention and treatment among persons who use drugs. Springer’s research plan is inspired by the U.S. Department of Health and Human Service’s Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to scale up key HIV prevention and treatment strategies with the goal of reducing new HIV infections by 90% by 2030. EHE consists of four components: test, treat, prevent, and predict. Springer’s vision is to fill the gaps in each step and to integrate substance use disorder—especially opioid use disorder—into the initiative.
At the center of her work will be a mobile health clinic and pharmacy. She will be targeting people at risk for HIV and at high risk of overdosing.
To overcome testing and treatment barriers, Springer asserts that medications need to be available where people live — housed or not — and be provided by people they trust. The first step is recruiting people living in communities with high rates of HIV and SUD and training them to be community health workers (CHWs). CHWs would be trained to perform rapid, point-of-care HIV testing of people in their area and to diagnose opioid use disorder and other substance use disorders. They would then link them to care.
“It’s got to be people that mirror that community, mirror the people that are affected,” said Springer. She maintains CHWs could be anyone, even someone unhoused. As she prepares for to kick off the project in Connecticut, she will be working with Alliance for Living and the Department of Public Health to help identify CHWs. Word of mouth plays a role, too.
If after testing, if patients need care, they will be linked to a clinician accessible via telehealth. Clinicians would be able to prescribe medications that will be dispensed in real time from the mobile hubs. Medications will be made available on the mobile hub from retail pharmacies where pharmacists will direct the dispensation. In collaboration with CHWs, pharmacists will ensure people get medications the same day if needed, as well as timely refills.
“I think pharmacists are going to be invaluable to this,” said Springer. Patients may not have access to a traditional pharmacy nearby, and even if they did, it may not stock the medications needed. Health insurance, which is necessary for telehealth, is another barrier Springer is working to address.
For prevention, the mobile response team of a trained CHW, pharmacist, and online clinician will rapidly provide PrEP (pre-exposure prophylaxis), medications for opioid use disorder and naloxone, and access to syringe services programs. Lastly, Springer plans to collaborate with scientists to predict where outbreaks may occur in order to rapidly deploy prevention and treatment there.
Putting the plan into action
The Avant-Garde Award provides five years of funding. Springer is using the first year to set up the mobile pharmacy, hire community health workers, meet with partners, and evaluate cost. Because of supply chain issues created by COVID-19, it has been difficult to obtain a mobile health unit, but Springer hopes the unit will be ready early next year.
The model will be tested in Connecticut first. Since rural areas have fewer resources, Springer will be focusing her efforts there, starting with Litchfield County. “This is a real world, implementation project. It’s not a randomized control trial; there is no strict eligibility,” said Springer. “It’s trying to find the communities and bring the services to them.” Once the model is evaluated, she plans to bring it into other areas of the country who have mobile units to see if it can be replicated.
There are two more barrier facing these populations in need of treatment, though: stigma and trust. “There’s a lot of local, community fear,” said Springer. She explained that some people believe that providing medications such as Narcan for substance use disorder will encourage drug use. “Every community is not going to accept that.
By partnering with communities, her hope is to provide a broader range of services they may need in addition to HIV and substance use treatments. For example, communities with more senior citizens may want blood pressure checks or treatments for diabetes and hypertension.
Stigma seeps into medical settings, too. In some areas, disclosing a substance use disorder can be punitive. And, due to the history of mistreatment against marginalized persons, many seeking treatment might distrust medicine entirely. That’s why the community health workers are key to the project’s success.
Springer knows these next five years will be challenging, but she’s ready for it.
“Many people just give up because it’s a lot of work, but we can’t give up,” said Springer. “We’ve got to figure this out.”