Reaching People Others Don’t
On a misty, chilly Friday in Seattle, Washington, Nina Kim, M.D., an infectious disease physician, boards the Bremerton Ferry with the small orange biohazard cooler she uses to transport blood work across Puget Sound. She is headed to Bremerton, where she’ll see patients in the satellite clinic of the Madison Clinic at Seattle’s Harborview Medical Center.
Before the satellite clinic opened in late 2007, patients in Bremerton and surrounding areas found traveling to receive care a tremendous physical burden. Trips to the Madison Clinic in Seattle and back can take more than 8 hours, including two hour-long ferry trips, commutes to and from the dock to Harborview Medical Center, and the time spent in the Madison Clinic waiting and examination rooms. The intensity of the travel required to get to Seattle for appointments would take its toll on most healthy people, let alone those dealing with a complex disease like HIV/AIDS.
Dr. Kim says the new clinic has brought people back into care by easing the burden of travel. The satellite clinic is housed in the Norm Dicks Government Center in downtown Bremerton. It is a partnership of the Harborview Medical Center, the State of Washington, and Kitsap County Health District. “We do it all here,” says Dr. Kim.
The Bremerton clinic was the brainchild of Bob Harrington, M.D., the medical director of the Madison Clinic at Harborview Medical Center (HMC), which is owned by King County and run by the University of Washington. Of the roughly 2,000 clients seen at the Madison Clinic, approximately 50 were traveling from the western part of Puget Sound before the establishment of the Bremerton clinic.
“We were already caring for people in that area, but transportation was
an issue for them,” says Dr. Harrington. “Our Bremerton patients would often
miss appointments.” Although the Bremerton Clinic was established as a 1-year
pilot project, all involved are hopeful that the Washington State Department
of Health (DOH) will continue its support. Dr. Harringon says that DOH and
Ryan White Part B funding has “helped us bring established patients back
into care by lifting their transportation burden.” He adds, “It’s also helped
us reach HIV-infected people who previously had no care.” (For more on Part
B, see The
HIV/AIDS Program: Ryan White Parts A - F).
Dr. Harrington explains that creating the satellite clinic required the DOH
to establish contracts with the Kitsap County Health District and HMC. The
clinic space, which is provided by Kitsap County, includes an examination
room and conference room. Although the space is comfortable for patients,
it was not set up for primary care, so staff have had to be creative in pulling
resources together to create a functional primary care clinic—with some help
from Ryan White HIV/AIDS Program Part B funding.
According to Dr. Harrington, “DOH and Ryan White funding helps us keep the
lights on. It’s allowed us to send University of Washington faculty physicians
to Bremerton every Friday and to provide medical supplies, a computer, administrative
support, maintenance, and a Kitsap County nurse’s salary.”
Part B AIDS Drug Assistance Program (ADAP) clients include people receiving at least one medication through ADAP and people receiving insurance services (premiums, co-pays, or deductibles) that provide access to medical care and medications. ADAP served a total of 157,988 clients in 2006: 84 percent (131,885 clients) received at least one medication through the ADAP, and 16.5 percent (26,103 clients) received insurance services.
People living with HIV/AIDS may be out of care for many reasons—from not qualifying for public programs like Medicare to needing services that local organizations don’t provide. But for HIV-positive people in Bremerton and the surrounding areas, the issue was limited HIV care providers in their region. Seattle has experienced HIV providers and support systems, but for people in Bremerton, the nearest specialist might be hours away. Of the nearly 200 HIV-positive people in Kitsap County, 60 had been traveling to Seattle for care, and many others had no HIV care at all.
Brian
Living with HIV since 1999, Brian stayed healthy without medication until 2007, when he became gravely ill with pneumocystic pneumonia and ended up in the hospital. “My doctors and friends were sure I wasn’t going to make it,” he says. He rallied, but he ended up in the hospital again, living on a health roller coaster.
Today, Brian is Dr. Harrington’s patient at the Bremerton satellite clinic. “Before I found out about this clinic, I spent 8 to 10 hours getting to Seattle on the ferry, waiting to be seen, trying to get my meds, and then getting back home,” he says. It’s hard to look at Brian and know that just a few months ago, he wasn’t sure he’d survive. He lost his apartment and the ability to live independently when his housing assistance ran out, but he was able to move in with a friend. “It’s my connection to friends that is the biggest factor in my still being here,” he says. “They don’t tolerate silence; they check in to make sure I’m okay.” Brian’s friends have even become involved in his care by meeting his case manager and encouraging him to heed his doctor’s advice.
Brian also values having a network of people actively involved in his care
as well as a doctor he can trust. “If I met someone who was recently diagnosed
with HIV, I would steer them to this clinic, because being happy with your
doctors, like I am, is really important. I’m lucky.”
Life Changes in a Moment
Darlene is a great-grandmother raising her 2-year-old great-granddaughter. She is also HIV positive and, at 56 years of age, reflects the rise in HIV/AIDS prevalence among people age 50 and older. Darlene is a patient at the Bremerton clinic, where about one-third of all clients are women.
“Before my diagnosis, I didn’t have any of the things they tell you are risk factors. I wasn’t promiscuous; I didn’t use drugs,” Darlene says. After a divorce, she became involved with a man she met at work. “We stopped having protected sex, but we had ‘the talk’ about HIV status.” It was only after she found a pill belonging to her partner that she called the health department and found out the truth.
“They told me the pill was an antiretroviral. I thought that meant a drug to protect you from getting AIDS. I was shocked when they told me the drug was for people who had HIV or AIDS already.” She immediately was tested. “I waited 2 weeks to get the results—the longest 2 weeks of my life.”* Darlene soon found out that she was infected. That was in 1995. “The virus really knocked me down.”
Like Brian, she had been making the trek to Seattle before the Bremerton clinic opened. The trip was long and exhausting, especially with her great-granddaughter, car seat, and stroller in tow. “It was overwhelming to go through traveling and waiting and more travel every time you needed to go to the doctor.” Darlene now only has to drive 15 minutes to get care at the Bremerton clinic.
No Valley Too Low
Nestled within Yakima Valley, celebrated for its fruitful vineyards and orchards, is the small city of Yakima, Washington. HIV-positive people here are surrounded by rich natural and other resources, but accessible and affordable health care is not among them.
With the Ryan White Part B Program, the New Hope Clinic in Yakima has served 254 patients. New Hope is located within the Yakima Valley Farm Workers Clinic, which provides medical and dental care, educational training, substance abuse treatment, nutrition counseling, and other services. It serves predominantly Hispanic, migrant, and seasonal farm workers in rural Washington and Oregon. The clinic is one of the largest of its kind in the Nation.
David Tucker, M.D., was serving those hard-to-reach patients when he was
suddenly killed in a car accident in 2007. His death left a huge void for
those living in this rural area. “There was no doctor set up to take his
place and care for his patients,” says Debra Adams, program administrator
at the New Hope Clinic. Tom, age 57, depended on Dr. Tucker. “Although I
was with him a short time, Dr. Tucker made me feel not just like a patient,”
Tom says. “He gave me hope, encouragement, and treated me with integrity.”
Since Dr. Tucker’s death, Tom and other former patients are being cared for
by Neil Barg, M.D., medical director at New Hope Clinic, and his staff. “Dr.
Barg has been able to pick up where Dr. Tucker left off. We’ve worked together
on adjusting my treatment, something Dr. Tucker had planned to do, and now
my virus load is undetectable and my T-cell count has never been this high,”
says Tom.
Tom’s victories can be partially attributed to the AIDS Drug Assistance Program
(ADAP), which is part of the Part B program. All U.S. States and Territories
receive ADAP grants to provide HIV treatment for the
underserved. ADAP funding can also be allocated for services that enhance
access to, adherence to, and monitoring of drug treatments as well as to
purchase health insurance for uninsured people living with HIV/AIDS who would
otherwise lack coverage.
Since 1996, ADAP has been the single largest part of the Ryan White HIV/AIDS Program in terms of funding, providing services to an estimated 163,927 people in 2007. Nationally, more than 80 percent of ADAP clients have incomes at 200 percent or less of the Federal Poverty Level. (See also The HIV/AIDS Program: Ryan White Parts A - F).
Notes
*Today, the results of rapid HIV testing—administered by many HRSA-funded
sites—can be delivered to the patient at the time of testing.