Testing changes show a more stubborn, wide-spread HIV in San Antonio

When the Texas Department of State Health Services released updates to their 2010 study on HIV/AIDS just before Christmas last year, something seemed amiss. It’s an impressive document, filled with a host of information: breakdowns for populations described by age and race, regression estimates, and other details that would be confusing to anyone not a medical statistician. But one of the stats in particular struck me as odd. A bar graph on page 31 shows the prevalence of people living with HIV in Texas urban areas. San Antonio is placed right in the middle of the chart, occupying the median position, showing that 232 out of every 100,000 people, or .232 percent of the metro area population, is known to be infected. What’s strange is not just the relatively low number (Houston is shown at .393 percent), but that preliminary reports from the University Health System were already revealing HIV-positive results much, much higher — around one out of every 100 people being tested, or a full one percent.

Why the data spread? The DCHS report states known numbers of HIV-positive people, not projections. Perhaps the UHS data was skewed. Without consulting the experts, I’d never have a clue. So after making an appointment to speak with Dr. Roberto Villarreal, the UHS vice president who obtained the grant to fund new routine HIV testing, I caught up with Matthew Poe to start getting up to speed on the subject.

A burley ex-military medic who went into nursing after he left the service, Poe is the HIV Testing Coordinator at UHS. We met at TriPoint, a community center off North St. Mary’s near Highway 281 that combines a coffee shop with a YMCA health club and meeting rooms with wi-fi access. We sat down at a table away from the door, and for an hour or so we talked testing.

Poe had, he explained, worked all over before hiring on at UHS, where he is responsible for keeping track of the test results, informing patients of their HIV-positive status, and making sure they get linked to treatment. Funded by the state health department and the CDC (the national epidemiology experts, the Centers for Disease Control, based in Atlanta, Ga.), the new opt-out routine testing program began at two UHS ExpressMed clinics in 2010; testing at the ER at University Hospital began October, 2011. At the time he began the new job, Poe admits, he didn’t think HIV was much of a concern anymore. “I have been a nurse for 20 years, since 1991, so of course there was concern about AIDS then,” he said. “But the last few years, to be honest, I didn’t think much about it, except for universal precautions.”

The words “opt-out,” and “routine” are key — most HIV testing in Texas (and the U.S.) has been on an opt-in basis; the patient has to request it. Though many assume they are tested for HIV whenever blood work is done, testing has not often been routine. But in 2006, the CDC recommended that opt-out testing become the norm to fight the epidemic that after 30 years is still claiming lives. The first opt-out testing in Texas began in 2008 and most states are now moving to comply with the CDC guidelines. At UHS, HIV testing is administered to everyone who has blood drawn at the three participating units, unless they specifically decline the test. “That includes patients who have been rushed in from car accidents, women in prenatal care, and the very sick who have no regular doctor,” Poe said. The positive test results under the new testing regimen reveal that many patients have been diagnosed positive before, but either were not linked to care or dropped out of the system. Others are newly discovered cases. “When I got recruited to do this job, I got shocked. … You can probably go into any health care system’s urgent care clinic and complain of an STD and see if they test you for HIV,” Poe said. “There are probably a lot that do not.” Many health care providers have, he believes, become complacent. “We have fallen back,” he said. “Doctors are aware how to treat HIV/AIDS medically, but as for being proactive and doing the routine test — it’s not happening.”

Here in San Antonio, there is very little public clamor about HIV; unlike many other cities, there are few PSAs encouraging people to get tested or telling them where they can go to do so. Though national organizations like the Ryan White Foundation donate millions in grants to Bexar and surrounding counties for HIV support, the bulk of HIV education in the schools and testing on the streets of SA is done by scrappy local nonprofit outfits. They are taking the lead both in getting word to SA communities about the continuing threat of HIV, and bringing back proof of high HIV-positive rates in SA neighborhoods to the authorities.

San Antonio AIDS Foundation teaches HIV awareness classes to over 20,000 students a year in SA schools across 13 different districts. They house patients on-site, maintain a transitional residence on nearby Carson Street, and case-manage about 1,000 people in the community, providing them with hot meals and rental assistance. In addition, SAAF offers HIV testing. Jill Rips, the deputy executive director at SAAF, met me at their facility on Grayson Street, saying that many who test positive at SAAF are quite young, only coming in for testing after they’re already sick. “People are — like the early days of AIDS — showing up who just found out they were infected with HIV, and they have advanced AIDS, too,” said Rips. These extreme new cases aren’t far from the norm at SAAF. A third of the people who they test positive for the HIV virus develop AIDS within a year; a quarter within a month. Rips expects that after the annual numbers are tabulated next month, they will find that they tested about 3,400 people in 2011.

“We are still seeing a lot of new cases involving men having sex with men [known as MSMs]; but they may not be identified as gay,” Rips said. “They may have relationships with women; they may be married.” Of the population groups most at risk for HIV, MSMs and intravenous drug users are still at the top. In SA, and nationally as well, ethnicity plays a part, with African Americans most at risk, followed by Latinos, then Caucasians. Men tend to account for 75 percent of those testing positive nationally, but black women are increasingly more likely to be effected. Socioeconomic factors also come into play. The one-in-a-hundred testing positive in the UHS studies in San Antonio make sense when compared to a 2010 report by the CDC on HIV incidence among heterosexual inner-city poor, who have rates around 2 percent positive, with very little variation across ethnic lines. Half of the people being tested at UHS have no insurance. Poverty itself is a major risk factor for HIV in cities.

Testing of SAAF’s high-risk population (many are gay, poor, or both) returns rates at about 1 percent HIV-positive. And a new project funded by DSHS will enable SAAF to go after the highest-risk group, MSMs. They are ordering 98,000 condoms to distribute at bars and bathhouses, and will try to get as many men as possible into testing. They don’t have a test van, but they test out of tents at events and even out of their cars. Rips mentioned that the best way to slow down the epidemic is to let people know they are infected, asserting that a full half of new annual infections “are attributable to the 25 percent of the population who are unaware of their infection.”

But even Rips, who knows the face of AIDS in San Antonio as well as anyone, sees the routine testing being put in place at UHS as momentous in what it may reveal. In SA, newly diagnosed HIV cases hover every year between 250 to 300 new cases. “But instituting routine HIV testing could be a game-changer,” she said.

As of last September, another SA provider, Centro Med, also started doing routine testing. The extra blood draws will, no doubt, uncover yet more people with HIV. A law of the testing universe seems to be: the more tests, the more positive results. Translation: it’s a lot worse than we thought.

Rips walked me down the hall to meet Neida Gonzalez. “I found out because I had surgery for gallstones,” said Gonzalez. “They asked me if I wanted a test, I said sure. It came back positive. I take medications for it.” Gonzalez received her diagnosis in 2001 and has been an in-patient client at SAAF for three years. “One of my sisters disowned me because I have this disease. I love her, but from a distance,” she said. “I keep a good attitude, I’m very spontaneous. They call me a ‘walkie-talkie’ because I walk around talking to myself, but it’s not true. I’m talking to Him.” She points above. I ask if I can take a picture. She agrees, flashing a peace sign, but demands that I deliver a copy of the issue to her in person, even though there is a Current rack in the hallway. When Gonzalez is up to it, she talks at the schools that SAAF visits. “I tell the young ones, don’t be afraid. Whether you’re straight, gay, or lesbian, come and get tested. Read the pamphlets, its important.”

BEAT AIDS began on San Antonio’s East Side back in 1987. Today, the community-based group serves all of Bexar County, teaching HIV awareness classes at San Antonio College, St. Phillips University, UTSA, and the Eastside Boys & Girls Club. They reach about 15,000 young people a year. During Monday’s Martin Luther King, Jr. March they’ll be offering testing at the Davis Scott Family YMCA. And, as usual, they’ll be marching, as well.

Charles Whitehead began as a tester at the facility; now he is the prevention program director. “We traditionally target high-risk areas in the East Side; street corners, gay bars, the areas that are harder hit,” he said. Recently, their test results have ranged from 2 percent to 3 percent positive, proof of both the severity of the epidemic in the inner city and of BEAT AIDS’s ability to find and gain the trust of people practicing high-risk behaviors.

The Eastside’s black neighborhoods have been hit hard, but the community is fighting back. Nine black churches participated in HIV education last year, and they are reaching out to pastors at other churches to join in this year in a collaborative mentoring effort initiated by BEAT AIDS Executive Director Michele Durham.

Though Whitehead admits the organization is “not quite where we want to be yet,” they are growing stronger. They have a large outreach staff of 15, some have been with the community-based organization for 20 years, and they’ll be boosted by a certain star power when Martin Luther King III joins their staff at the Davis Scott testing booth next week. “The people we see are dual- and triple-diagnosed: HIV-positive, homeless, and have mental health issues. Not everyone can deal with that.”

Matt Poe calls me back and says I should speak with two of his colleagues, Melissa Lujan and Blue Cochran. They work for separate departments of the Center for Health Services. “The Center is the big mental health, substance abuse, and homeless agency in this town,” says Cochran. “They also have the methadone program, run the Prospects Courtyard part of Haven for Hope, and the substance-abuse program there, too.”

While men are the focus of much HIV-awareness and testing, Lujan, a clinical practitioner at Centro de Vida, works primarily with women. Her specialty is substance abuse and commercial sex work.

“Whether they shoot or snort heroin, or do some crack, we’re not asking the right questions,” Lujan says. We’re talking by phone — she spends a lot of time on the street, and it has been hard to settle on a meeting time. “You need to identify how they’re using the drug. We’re seeing a high use of Xanax, but they’re mixing it with heroin and shooting it. We are seeing some ODs.” As an abuse specialist, Lujan is concerned about the deaths; but there are other consequences. “Speedballs are popular, too. This means more erratic decisions, and users are less likely to negotiate any kind of safe sex when it comes to sex work.” She points out that SA has a high number of sex workers. With the military bases, it’s a garrison town. There are the tourists too, of course.

She says that people still are not disclosing their status, even in the gay community, which after so many early losses, should know better. “Basically,” she says, “it’s don’t ask, don’t tell. … Older positive men are picking up young hustlers — it’s human trafficking if they’re under 18, whether they are doing it by choice, or for survival.”

Cochran is a clinic administrator at the Center’s HIV Early Intervention. When her group finds someone who is positive, she sends them to UHS where Matt Poe makes sure they get linked into treatment. “We do psycho-social assessments: Do they even know what’s happening? And we tell them right off the bat there is financial assistance,” she says. “When they find out what their meds cost — which averages about $1,800 a month — they figure, ‘Well that’s it. I might as well die.’ But there are programs. I try to screen them for any excuses.”

But her young patients don’t take the disease seriously, she says. “I have one young guy that only comes in once a year when he gets sick. I’ve been seeing him since he was 18, and he’s 24 now. He’s lost, one of my lost boys.”

Increasingly, young women are being found to have HIV, too.

“We had a girl at Baylor University who went to a blood drive and found out she was positive. She had only been with two partners. A freshman at Baylor, it was the last thing on her mind.” Assumptions of safety are no longer valid, she insists. “If you have had sex, you are at risk. Period.”

Truly, anyone can strike out.

“Daniel” (who spoke to the Current on the condition that his name not be used) called up last week to offer his story. He learned he was HIV-positive in May 2011 at the age of 64. Raised in Alamo Heights, he worked in the high-end hospitality business. After his first restaurant in the Virgin Islands was wiped out by Hurricane Hugo in 1989, he spent time in British Columbia before returning to SA to take care of his aging parents. Divorced with an adult son, Daniel lasted six years in a second marriage before breaking it off. “As I approached 60, it wasn’t part of the plan to be single. That’s when I picked up the Current, looked in the back [personals section], and said, ‘This’ll work.’ And it did, very well.” When he turned 62, he developed shingles (“You know, that old person’s disease?” he said). It was only after a year of going to various doctors, that one of them finally tested him for HIV. He started medication immediately and the shingles, a painful viral disease affecting the skin of the torso, went into remission. “Making sure you take your meds all the time is critical, or you put yourself in jeopardy,” he warned. “I consider myself to be one lucky guy.”

Finally, it was time to meet Dr. Villarreal downtown at the Robert B. Green campus on Martin Street. “Yes, there is a lot of misunderstanding. It is true that we have better drugs, and better treatment, and understanding of the disease, but the epidemic is still there. There is a feeling that we are under control, we don’t have to take precautions, we don’t have to ask questions, and everyone can be happy and pursue the American Dream,” he says. “It’s far from the truth. People are still getting infected.”

Nationally, teenagers are getting HIV, regardless of their sexual orientation. Women are getting HIV because their husbands transmit it to them, not because they were involved in high-risk activities themselves. And old myths continue. People still think that you only can get HIV from needle use or homosexual sex. That’s not true, but there are other misconceptions. You can’t get it from talking to someone who has HIV, but people still believe that, too. “People forget that the largest numbers of people lost to AIDS in the beginning of the disease were due to lack of controls in blood transfusions and organ transplants,” Villarreal says. “They just see it as a gay disease.”

The one-in-a-hundred numbers coming out of the ER are not unexpected among medical insiders, he says, as the samplings are happening within an ill population to begin with. “We are the county hospital. By nature, we get the biggest proportion of very sick people here.” While many of the patients have been in other emergency rooms, they may never have been tested for HIV. The difference now is they’re being offered testing.

Villarreal insists we recognize an underlying problem, another sort of epidemic. “In the health care system of this country, a lot of our behavior is driven by the payer — insurance, Medicare, Medicaid — so the physician orders what he can bill.” Quality of life, it seems, is an afterthought.

Of those who arrive at UHS, about half are uninsured, but the UHS financial assistance program known as CareLink provides help, including, says Villarreal, “a medical home, a primary care provider, and all the services we have.” With the cut-off point for eligibility at 300 percent of the poverty rate, it’s an important resource that helps many. “These are people who are working, a lot of construction workers, hotel workers,” he says. “Even in the school districts many have no insurance because it would be a quarter of their check.”

I ask Villarreal if city leaders have offered much support.

“About a year ago we had a meeting with the mayor; myself and Dr. Jimenez, the chairman of our board, were there. It was organized by all the groups that were concerned that the city is not taking a lead doing something with HIV. The mayor was very supportive of that and responded that it would be one of his priorities after economic development. But not too much has happened after that.” (Calls to Castro’s office were not returned by the Current’s press deadline Tuesday.)

Action can be daunting. “Having worked in disease prevention almost all my life, I know that there are always institutions that will not be eager to participate, wondering, ‘What are we going to do with these patients?’ If you are the CEO, the chief economic officer, that can be a great load — are we going to need more nurses, more doctors? Are we going to need more support?”

Although Houston’s HIV rates are still higher than San Antonio’s, that may change as more aggressive testing continues, Villarreal says. Testing may indeed prove to be a game-changer: insisting we pay more attention to something we collectively ignore so well. What then?

The state might reclassify Bexar County, and allocate the additional resources that are delegated to areas with higher HIV rates, but the epidemic must finally be publicly and honestly wrangled with by the whole community. Medical resources alone will never suffice. •

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