Caring for Patients with HIV/AIDS
As medical director of the Immunodeficiency Center at Einstein Medical Center Philadelphia, Jody Borgman, MD, has witnessed many positive developments in the treatment of HIV/AIDS.
“It’s been extremely rewarding,” says Dr. Borgman. “I’ve seen tremendous breakthroughs and changes in medication. For many years, we couldn’t get patients to take their medications because the regimen was so difficult. There were so many pills, and there were lots of side effects from the pills. Now, most patients can be offered a single tablet to take once a day, and if they’re compliant, they should be able to control their HIV (the human immunodeficiency virus, which causes AIDS).”
The Immunodeficiency Center opened in January 1995 with the mission of treating patients with HIV/AIDS. It is located in Einstein Philadelphia’s Community Practice Center.
Currently, the Immunodeficiency Center has about 850 patients on its roster, most within a 15-mile radius of Einstein Philadelphia. (There’s also a half-day session at suburban Einstein Medical Center Montgomery with about 100 patients.) Most of the patients are on medical assistance, and most come from underserved communities. There are patients as young as 18, and as many as 10 to 15 in their 80s. Roughly 30 percent are women.
“The risk factors run the gamut,” says Dr. Borgman. “It’s men who have sex with men. It’s heterosexuals and former IV drug users. We have all the different populations.”
A Staff with Broad Expertise
Besides Dr. Borgman, the staff of approximately 15 includes nurse practitioners, dietitians, social workers and a behavioral health counselor. There’s a testing group, which includes testing coordinators for both HIV and hepatitis C—a serious infection that in many cases can lead to liver transplantation.
A full-time nurse visits patients in their homes. “She helps manage their medications, deals with acute issues, and helps them make sure that they get to their appointments,” says Dr. Borgman. “We refer our most difficult patients to her to help coordinate things. It’s great to have someone like that.”
The Immunodeficiency Center is a full-treatment clinic, which means it offers care for all of a patient’s health needs—from diabetes to high blood pressure to STD screenings. These issues can be serious and complex. In many cases, Dr. Borgman tells patients, HIV is the least of their worries.
The center also deals with mental health and social service issues.
Each of the four social workers has a particular niche, Dr. Borgman says, ranging from health insurance coordination to making sure that patients, once they begin care, continue their care.
In spite of the center’s best efforts, patients do sometimes stop receiving treatment, and Dr. Borgman says that can be a source of frustration. “It can be a challenging population. Some of them fall out of care because they lose their insurance and don’t realize we can help them with that. Others fall out of care because they have issues with either drugs or a psychiatric illness, and they don’t really commit to care.”
Still others stop seeking help because—in spite of all the medical advances of the past 20 years or so—the stigma associated with HIV/AIDS remains. “They have a hard time dealing with that so they fall out of care,” he says.
When patients stop seeking the kind of help they can receive at the center, they start to lose ground. “Our goal,” Dr. Borgman says, “is to keep them in care and prevent that from happening.”
Dr. Borgman recalls one recent patient who seemed like he might go down that road. In the end, hard work by the center staff kept him on track. The patient had been hospitalized at the beginning of 2017 with toxoplasmosis—a parasite-borne disease that in an HIV-infected patient can cause severe symptoms, including seizures, poor coordination and confusion. “He actually did well with the treatment initially, but we had a lot of difficulty keeping him in care,” Dr. Borgman says. “He wound up being readmitted three or four times in the first couple of months, mainly because he wasn’t taking the medicines as directed. And part of that was because he hadn’t told his family about his illness.”
Because the patient was from the Caribbean, there were cultural and language barriers as well.
The staff had difficulty contacting him but finally, he came in for treatment. It was then that the mental health counselor began working with him. The patient had been depressed about his diagnosis. After a considerable amount of one-on-one care, says Dr. Borgman, “we were finally able to have him buy into the program, and have him understand how we could help him. He still continues to come back.”
What’s more, his CD4 count—a test to determine how well the immune system is working—had increased to the point where his disease was close to being undetectable.
Hope for a Cure
Success stories like that are part of what keeps Dr. Borgman engaged, in spite of the occasional frustrations. He trained in general internal medicine, thinking he would become a primary care provider. He also hoped to have a special niche. “I wasn’t really sure what it was,” he recalls. “I thought it might be rheumatology and I kind of explored that for a bit and found I didn’t really like it.”
Then one day, Ernie Peacock, then HIV program coordinator for Einstein Healthcare Network, approached him and asked him if he would like to join the new clinic. “I jumped at it,” Dr. Borgman says.
Part of the appeal for him was that “nobody knew a lot about it then. It was a field that was just starting out. I was lucky to have gotten into it at the time. I was able to take it from the beginning, and I learned and saw so many changes along the way. I kind of grew along with the epidemic.”
Now, he hopes for the day, still probably many years off, when the Immunodeficiency Center no longer has a job to do.
“I’m waiting for the moment when we finally have a cure,” he says. “People ask all the time, ‘When are we going to get a cure?’ There are a lot of things that are happening that suggest we are getting closer to a potential cure. We’re probably 10 to 15 years away from that, at least. But I do see a light. I’d like to someday say, OK, cure everyone in our group, and close the door.”