Testing, delivering results, and linking to care: A Q&A with Derrick Butler, M.D.
" I'd rather tell someone he or she has HIV than that he or she has cancer," said Dr. Derrick Butler, director of the HIV program at T.H.E. (To Help Everyone) Clinic, Inc., in Los Angeles, California. "I know after that I have something better to tell them. HIV is serious, but it doesn't have to be and should not be terminal."
Dr. Butler is a Morehouse College graduate and University of California, San Francisco, trained family physician and HIV specialist focused on addressing both the current HIV/AIDS epidemic and the general health disparities of urban populations. He credits being a medical student in San Francisco in the 1990s for his comfort level with HIV/AIDS.
T.H.E. Clinic, Inc., is a federally qualified health center that has provided underserved communities in Los Angeles with access to high-quality health care and preventive education for more than 30 years. Patients run the gamut of age, gender, and ethnicity—more than 60% are African American, 26% Latino, 10% Asian, and nearly 3% are Caucasian/other.
We sat down with Dr. Butler to learn more about his patient population, hear his perspectives on routine HIV testing and delivering positive test results, and listen to his advice for providers on linking HIV-positive patients to care.
Can you describe your patient population in more detail?
Our predominantly low-income population has many of the typical chronic diseases—diabetes, hypertension, substance abuse, recreational drug use, and so forth. Most patients have a high school education, if that, or are monolingual Spanish-speaking workers in low-paying jobs. That's why I practice there—all of those social factors affect chronic conditions and interfere with health and wellness.
What is T.H.E. Clinic's approach to HIV testing, and how has it been implemented?
The Ryan White Clinic has been part of T.H.E. Clinic, offering testing for approximately 20 years. In 2009, we received CDC funding via our county HIV program for a pilot project looking at rapid routine testing for areas with higher HIV prevalence. We expanded that to educate our primary care providers, as well, and get them to test as many patients coming through the door as we could with the noninvasive OraSure test.
We do opt-out testing on all new patients receiving blood draws for routine screening labs. We present the HIV antibody test as part of comprehensive routine health screening. I never separate out the HIV test as something special or unique. I emphasize that all tests being performed are relevant for complete health screening. After the initial test, repeat testing can be risk based.
How do you deliver positive test results?
Usually the patients have a followup appointment scheduled to review their test results. If they test positive, I will call them in earlier to discuss their results. I make it clear to our staff that this diagnosis should always be given in person and delivered as naturally as any other condition. Patients read your body language and feed off of that with their own anxiety. You never know how informed they are about HIV. After looking at the patient and assessing his or her reaction, the first thing I say is, "You are not going to die from this unless you choose not to take care of it."
Some providers are uncomfortable giving positive results, but why? They tell people they have cancer and diabetes, which are potentially fatal. HIV is easier to treat if it's caught early. The fact that 85% of people contract HIV sexually makes doctors uncomfortable. First, clinicians need to examine their own feelings about HIV, stigma, and so forth. HIV is a medical condition/virus that we can treat. Second, they need to focus on getting their patients linked to care.
What tips do you have for providers regarding referrals and developing relationships with HIV specialists and AIDS care organizations?
Providers should become familiar with resources like the American Academy of HIV Medicine, which provides an online referral link. And most university centers and medical schools have HIV experts associated with them—in some States, these centers are the only HIV clinics. Most primary care physicians have a go-to person for every kind of condition, so they could likewise reach out to trained HIV specialists before they deliver positive results. Make some calls or send e-mails to establish contacts with doctors, case managers, or nurses that you can refer your patients to, so they don't get lost. I prefer the more community-based Ryan White–funded clinics. Reach out to them or the local AIDS service organizations to introduce yourself and the fact that you'll be testing, and ask how best to have your patients access them. Early on, more hand holding may be needed. Helping tighten these linkages will keep patients from getting lost in care.