Dr. Anu Hazra is an Assistant Professor in the Section of Infectious Diseases and Global Health. He is also CCHE’s new Director of STI Services. He was kind enough to sit down and speak with me about his past work, current passions, and overarching thoughts on what it will take to the importance of sexual health and sexual wellness work. Dr. Hazra brings a moral clarity and drive to all the work he does and we look forward to his innovative walk-in STI clinic he founded at the University of Chicago’s Medical Center.
The transcript (edited for clarity) can be found below.
Introductions and Background
Sarah Nakasone: Okay, um, so I think just kind of broad question generally before coming to us?
Anu Hazra: Yeah, yeah, yeah. I moved around a little bit, originally grew up in New Jersey – well, originally, originally born in the suburbs of Chicago, in Naperville but really grew up in New Jersey when we moved there. I went to undergrad and med school in Boston, at Boston University and I came back to Chicago for residency, I was at Rush where I was a doing an internal medicine residency. And then, I sort of went back to Boston for my ID fellowship, um, infectious disease fellowship at Beth Israel Deaconess Medical Center and Harvard Med and sort of came back here when I saw this job opportunity posted at the end of my fellowship and had to check it out.
SN: How’d you get interested in HIV and Infectious Diseases?
AH: I think I’ve always had an interest in HIV, really since undergrad. I really liked my immunology coursework a lot and we really used HIV as a textbook example of how to sort of explain different pathways and what not. I was an African studies minor in college as well, so did a lot of – took a lot of coursework in mostly sub-Saharan Africa and looking at sort of the intersection of society and then in terms of the legal system down there, and the medical system – the intersection of all those really were where HIV was and that really interested me a lot, too. And then it was only when I got to med school, I realized I could make a career out of this, I mean, before I only thought it was something really interesting to learn about, talk about. But I couldn’t really see how this formed into a career. So, once I got into med school, working with infectious disease physicians and HIV docs, I realized I could make this into a career, which was awesome.
SN: I’m interested in the coursework you were doing in sub-Saharan Africa, because I did my thesis work in South Africa around PrEP.
AH: Cool!
SN: So, what specifically were you interested there around HIV?
AH: So, I think I – it was so funny how I even became an African studies minor. We have to take a – in undergrad, I remember, we had to take a mandatory writing course. I ended up – my writing course, as a freshman, you don’t really get the opportunity to choose, you’re just placed into one. And I just happened to be placed into one on post-apartheid South Africa. So, writings in post-apartheid. So, J. M. Coatzee, and then a few other authors. And the professor was awesome, and I didn’t realize that BU had a pretty robust African studies department. And so, you know I took a second class that was like the continuation of that writing course. I liked it a lot. And then I started taking a few more courses, took – looking more into sub-Saharan and South African art history, particularly around the AIDS epidemic and the art around that. And then, there’s another, sort of ethnography course that I took, all of it sort of meandering though. And then I realized that I had enough credits for like a minor, and I’m like, “sure, why not.” But I think I would always circle back to how different societies in sub-Saharan Africa reacted to the AIDS epidemic and how they sort of addressed it themselves. Um, yeah, I thought that was super interesting.
SN: It was a different world working there, seeing the people respond to it.
AH: Yeah.
SN: But you stayed king of local for a career. Did you never think that you were going to do global health after medical school?
AH: Yeah. So, I think – so, I wasn’t able to go abroad in undergrad just because the timing wasn’t right. And then in medical school, there were just a few other things that caught my attention. I was working at Fenway Health for a little bit and there was other stuff that I just didn’t have the opportunity to go. In residency –something every step of the process there was something that got in the way that I couldn’t. And there were other interests I had. I was able to finally go to Botswana as an ID fellow this past year. Spent 6 weeks there which was an amazing experience. I was glad I was able to experience that. I think I find much more – I feel like I can make the most impact domestically, here. The way I feel like, my skill sets and what not. So, in the end, I have an interest in understanding the global epidemic but where I feel I can make the most change is in the communities in the United States.
Path to CCHE
SN: I always have to ask that question because I get it asked of me repeatedly given that I worked in Chicago and also South Africa. But okay, you do all this work, you get though medical school, you get through residency, and then you see – or, after working at your fellowship, you see this posting here at the University of Chicago. So, what appealed to you about the posting?
AH: Well, a few things. It’s actually funny how life works. The summer after my first year of med school, I actually worked with John Schneider and he was the first infectious disease person I actually ever worked closely with. And so, I spent 8 weeks with him back in ’08 and really got to see – this was way before CCHE and all that. He was back at Access then. But it was the first time I was actually seeing HIV patients in the clinic and what not. I thought – that really for me cemented my interest in ID and that’s when I was making a mention – “Oh, I could really make this a career.” It’s really by looking at John, Jean Luc, Dave Pitrack, those people I sort of saw that summer, I realized this could be something I do for the rest of my life. Which is super exciting. And, so then I think when I was finishing up fellowship, my husband and I we were always going to be either in Boston – my family’s in the East Coast, his family’s in Chicago so we were sort of juggling between the two. We missed Chicago a lot, so we were planning on moving back to Chicago. So, I was essentially looking for jobs. So, I was in contact with where I did residency as well. And then, I found this position posted and immediately from the description, I knew this had to be something John was part of. It mentioned CCHE and what not. So, I sent him and email and we discussed it. It’s hard when looking for jobs. You try to be objective and not get too excited by everything on paper because nothing always works out 100% in real life. But, I mean, everything John was saying about the job, everything fell completely in line with my interests and what I wanted to do and where I wanted my career to go. And, I had to sort of explore it more. I came out here to learn more about the position. And, knock on wood, it’s been about four months and things are sort of still exactly what I wanted it to be. So, again, it was funny how life works in that regard. Almost exactly 10 years later I’m back to working with John.
SN: It’s a terrifying thought for where my life will be in ten years.
AH: [laughs]
SN: What was it about the job posting that you were reading and it’s like, “That’s what I want to be doing!”
Passion and Plans for an STI Clinic
AH: I mean, it was expressly talking about working with gender and sexual minorities which is a population I’ve always wanted to work with from before I even applied to med school, I knew this was a population I identified the most with and felt that I could make the most impact. Talking primarily about sexual health and sexual wellness. And in the world of ID – in the world of infectious disease, sexual health and sexual wellness makes a very small niche and to find a job that focused on that was a super treat. It’s like finding a needle in a haystack. And that in a city where we want to live at a great university with someone I’m familiar with. All of these things fell into line. It’s crazy how things work out. But those things, working with gender and sexual minorities, working specifically with sexual health and wellness and then working primarily with STI and HIV prevention, these were all things I envisioned my career to be and I always thought I had to give up something in order to be there. So put my time in doing other things before I can get there. And to have that at my fingertips right off the bat was really, really special.
SN: What would be – because this is a new role for us. What’s your vision for what this position’s going to look like?
AH: So, the job that I’m doing that the University side is operationalizing a STI clinic out of the ER. From what I understand and from speaking with other people around the country, this is sort of new. The process would be essentially starting a STI clinic to offload the ER in one respect, and then allowing those patients to be seen up in the ID clinic where I would see them and we would be able to link them to care, same day PrEP starts, be able to link them to – directly to HIV care either with myself or someone else either with myself or someone else if their test came back positive. It’s just a way of having a more comprehensive look at sexual health, which I think sometimes does get ignored or what not. And then to do that, because a lot of people with STI symptoms often do present to the ER because these are young people who don’t have a primary care doctor.
SN: I get all those reports on my desk.
AH: Yeah, exactly. And so it’s a great way to sort of capture these people and really retain them in the health care system by providing culturally competent care and really just identifying in the end what their risks are, teaching them what their risks are, and then talking about how we can do risk reduction strategies, either through non-pharmacological techniques or through pharmacological techniques like PrEP and what not.
SN: I think that’s a really important point about culturally sensitive care because one of the things that we’re taught as students coming into the University is that the University does not have a good history with the area. So how do we, especially as a medical center, start to change that – where patients do feel like they can trust us, where they feel like they’re being seen when they come in for care?
AH: Yeah, I mean that reputation is known and something I sort of walked in with in my head as well. I have to say, though, at least my interactions with the infectious disease section itself has been sort of far from it. And I feel like the patients understand that. The way I can only combat, sort of that reputation is by providing the best care I can to patients I see. And my hope, or the goal is that this would be better known in the community itself, and that it would be almost a resource itself that the community could take advantage of. But, I agree, I think it takes a long time to sort of break those stereotypes or those views itself. Yeah, I think with the investment that the division is doing and CCHE is doing is noticed by the community as well. I think that perception is changing, at least to certain segments of the population on the South Side.
SN: Yeah, I agree with that. My work’s largely in women, so it’s not an area we’ve targeted.
AH: Yeah, and I feel, I mean, – I see this PrEP for women sticker on your thing.
SN: And my shirt.
AH: Oh yeah, sorry. But I feel like women have been consistently sort of ignored in this whole HIV prevention process. And I think it’s kind of hard. I talk to Alvie about this all time. I think women have a hard time gaging what their risk is, because it’s not what their risk factors are, it’s what the risk factors of their sexual partners are. And how do you understand that? It’s like one step removed that – who are their partners having sex with? And what are their partners’’ HIV risk? So even if they’re in a monogamous relationship or they’re having sex with one or two male partners, who are the sexual partners of those male partners? And I think that’s where the networking at CCHE is really interesting and it would be cool to see how we expand to women. I mean, New York has already started doing targeted PrEP campaigns to black and Latina women because they see them in the periphery as – their rate of rise is higher than any segment of the population. So, keeping an eye on them is important because it’s something that if we don’t intervene on will only get worse.
SN: All of my PrEP for women things have to come from London because that’s where all the attention – it seems like New York and London are the only two places and Chicago…
AH; Yeah. I feel good about sort of, at least some of the work coming out with the dapivirine ring, and at least there’s more work being done for women. But I think we’ve still done a really lousy job of trying to enrol more women. And a lot of that is sort of the restrictive nature of a lot the grants we get, all sort of based on just MSM or trans women of color. Not to say they’re not a risk group, they’re the highest risk group, especially in the South Side of Chicago, but if we’re really going to get to this elimination campaign, we have to start expanding to everyone else at some point too.
SN: No, it’s true. So with this new STI clinic we’re going to be doing, how does this fit in with the testing that we’re doing say at the Village, or the testing Howard Brown is doing?
AH: Yeah. So, I think the plan for the STI clinic is twofold. So, one, the University I think appreciates us off-loading a busy level one trauma, now, for sort of lower acute – your things that don’t, are not the best use of an emergency room itself. And then two, doing a comprehensive screening. So, doing triple site screening on every sort of male that comes in which doesn’t always get done in the ER. And then having sort of an easy way of following up on these results. And then linking them to care. So, they are engaged, or they want to get to PrEP, then sending them to Howard Brown or any of the other community affiliates that they would rather go to. But obviously if they’re at Howard Brown, they want to go there, then it’s easier for them to go to the Village and see some of the programs and engagement opportunities we have there. Um, I think from – I feel like myself, it’s more like a conduit between this ER, DCAM level of care to the general community. Because I have clinics out in Howard Brown, so I’m out there. So, it’s really easy if I see them, perhaps uninsured or they can’t be seen in DCAM for whatever reason, then I can be like, “Hey, you can see me, up on 55th street in two or three days.”
SN: How do you start diverting people from the emergency room? I mean obviously, you’re going to get anyone who walks in and says, “I want an STI test.” That gets sent straight to you.
AH: Yeah, so we’re in the process of working with the Office of Compliance and what not right now. It’s – it sounds really easy when you’re saying it but when you get ot the details it’s a little more complicated. There’s something called EMTALA, I forget what it stands for. It’s a rule. It’s Emergency Medical…
SN: I should know this because it was in class yesterday, but I don’t.
AH: Essentially it was, I think, it was created a decade or two ago and it was to protect patients from being turned away. So, if you come to the ER, you will be seen by an ER provider. They don’t have a time limit, but you will be seen by an ER provider. There’s something called a medical screening exam that every patient who comes into the ER needs to get through. And the medical screening exam essentially will let the ER know what level acuity this is. I mean, technically, if they don’t meet ER acuity you can send them to a clinic, but that has always been so difficult that the ER just sees everyone that they end up screening who comes into the ERT itself. What we would hope to do, essentially, at the medical screening visit if the provider screening them thinks it would be appropriate for just a medical screening in DCAM we would actually have a transporter who would be hired who would transport them from the ER to our clinic in DCAM. Ideally, the transporter would also be trained in phlebotomy so they would also be able to do blood draws. Sort of someone who would be able to do all these sorts of jobs in between, trying to get them form the ER to our clinic.
SN: That’s a really interesting idea, I’m excited to see how that turns out.
AH: Yeah! Like I said, it’s new from what I – from at least my cursory search and the people I know in the country. It hasn’t really been done before. And it would be really exciting if this model works to see if we can adopt it elsewhere. I mean, like I said, hospital administration likes it just because it’s better use of the resources that we offer. Because why would you go to the ER for STI care when there’s an STI specialist five floors up who can see you right away?
SN: Is it worries about insurance?
AH: Um, in terms of?
SN: If you walk into the ER…
AH: Right. For mostly the people who walk into the ER< even if they’re uninsured…. Do the patients get worried about insurance?
SN: Right, do you walk into the ER and just see this as your point of care because you think, “They have to treat me, then I’ll leave, I’ll never pay this bill.”
AH: Yeah, and I think we would still be wrapped into that. It’s not like they would be getting two bills from us. We’d be sort of wrapped into what they would expect anyway coming to the ER, except instead of getting care in the ER, they’d be getting care in our clinic.
SN: When are you trying to go live with the clinic?
AH: It keeps getting pushed back with meetings. I hope we can go live in the next month or so. I mean, my clinic’s already open so I’m seeing everyone else right now. And, yeah, the plan is hopefully we’ll go live in the next month so we can get this entire thing started. It’s five days a week. We’d be open for business for patients coming from the ER.
SN: I’m completely selfishly wondering now if I have to do all the reporting for that too.
AH: I don’t think so. No, no, because they aren’t being seen in the ER.
SN: Excellent! You can take away all of my reporting work! What else could you see doing in this job?
Passion for Education
AH: I would love to – I had a chief here in residency and that really solidified my interest in medical education. And it’s something that I was able to do as a fellow. And I would really love to turn, once the clinic is up and running, we work out all the kinks, I would rally love to turn this into an educational opportunity for both levels. I mean, both levels of medical students, from residents to fellows. I do think sexual medicine is often times not super stressed in medical training and just having a full STI clinic that you can go to or rotate through for a week or two. I would have liked that as a med student, even as a resident. Ideally, big picture-wise, I would like to create this educational elective for trainees as well. I think that would be a rewarding experience for them.
SN: I’ve been here for three years so I forget this is not everyone’s experience. Like, “Oh, of course, everyone does sexual health information.”
AH: No, exactly. It’s really sort of giving – there’s always a self-selective group that want to learn more, will learn more but I think it’s important no matter what speciality you go into being comfortable discussing sexual health topics is super important.
SN: What got you started teaching in residency and fellowship?
AH: I always enjoyed teaching, I tutored in undergrad and med school and stuff. What attracted me to internal medical school – you’re a third-year medical student now?
SN: No, no I’m an undergraduate.
AH: Okay. What attracted me to internal medicine was their commitment to teaching. And people arguably say – I think the best teachers I had were infectious disease. Really taking the time to understand what level each learner was at and be able to impart some sort of knowledge to them that’s at their level that they would be able to appreciate and use. So as a chief I was able to do a lot of educational opportunities with the residents and the medical students which I absolutely loved. As a fellow I was able to do the same both at the medical school there and at the hospital. And so it’s something I’m super interested in. Right now, it’s taken a backseat with everything else going on, but I am really excited to jump back into that or be able to involve that part of me more once everything settles down.
SN: No, that is really exciting. I don’t think most people – I obviously haven’t gone through medical school, but it’s not always the case that you get a chance to engage with the surrounding community even going through medical school here.
AH: Yeah, no, for sure, which is a shame.
Work with Fenway Health
SN: I wanted to kind of step back a little and a talk a bit more about the work you did before coming to CCHE. And you mentioned you worked with Fenway. Which I only know because of the faculty talk I think two weeks ago.
AH: Yeah. Doug Krakower is awesome. So, after I worked with John Schneider, that summer after my first year in med school, I was like, “John, this is something I really want to do, who do you know in Boston that I could connect with?” Because I only there for the summer. So, John connected me with Ken Mayer who at that time I thought was just a name John said, and then I slowly realized that Ken Mayer is this giant – he’s the medical director of Fenway Institute. He’s a huge name in HIV treatment and prevention and STI treatment and prevention. And so, I was connected with Ken who, I mean, for a guy who was busy as he was, he was super gracious with his time to help a second-year medical student navigate through what I wanted to do. He put me initially on some surveillance data collection that they were doing for the CDC. So, their STI data collection, doing a lot of chart reviews and what not. And then, when I worked with John that summer in Chicago and when I was doing this chart review project, I was just noticing a lot of syphilis, just a lot. Even then, back in ’08, we were seeing an uptick in syphilis. And then we would see a lot of these patients who would be diagnosed, treated and come back within 6, 12, 24 months, again with syphilis itself. And, “Oh, that’s interesting.” I didn’t see a lot of work out there on syphilis re-infection or rates of syphilis re-infection. A lot of times people always talk about syphilis, you get it once, you get treated and you learn your lesson. You never get it again. Some sort of, like, yeah, weird dogma that people think. SO then, I brought it up to Ken, I was like “Hey, what do you think of looking at the last five years to see how many people had syphilis more than once?” And Ken was great, he was like, “Sure, go for it.” And so, I was able to collect that data and sort of get a better idea of this population that gets syphilis more than once in five years. A lot of things were unsurprising. The re-infection case, almost 98% were MSM, several of them had concurrent gonorrhoea and chlamydia. And we saw like exactly the rate of seroconversion within 1 to 2 years. Like, syphilis begets HIV. It’s a huge risk factor for transmission for HIV. We saw that strong correlation, we saw a correlation between Hep C but it’s not as strong, but still significant. But it was still interesting seeing that signal there. And then we were able to implement some primary care strategies like if someone – this was right PrEP was, IPREX was just published later on then. And so, it was exciting. I think in the primary care setting in Fenway it helped put things on the map. Like, if someone’s coming in with syphilis for the second time, you need to convince me why they shouldn’t be on PrEP. And then so, when I – I was able to wrap that up before I graduated med school itself. When I came to Chicago for residency, I did some work in Cook County Jail with Chad Jacob, Chad Zawitz, which was really cool being able to rotate at Cermak which is the infirmary at the Cook County Jail. Seeing scores of detainees who are HIV positive. And it was interesting, I think it was probably the most well-controlled HIV I’ve ever seen anywhere else because I think all the ART was basically directly observed and so everyone was on medication or what not. And so Chad was looking at resistance patterns within the jail itself. Because the jail had just switched to opt-out testing, so everyone got a test when they walked in and all the positives got an automatic genotype. And so, we saw a lot of these genotypes trying to figure out what are some clusters we’re seeing in our detained populations? So, that was interesting, that was a lot of the work. I did some rotations at Howard Brown as a resident as well, which was cool. But then when I was looking to do fellowship, I reached out to Ken. I sort of wanted to do in my ID fellowship… I knew what I wanted to focus in by then. I wanted to do ID and I wanted to do sexual health and wellness and I wanted to see a lot of HIV and I wanted to see STIs. So, I was really looking at Chicago and Boston because I was talking to Ken and Ken’s like, “Well, FI has this program here, you could work with me at Fenway.” And so that really attracted me to – my family was still there, so I got to Boston for fellowship. Didn’t get to do a lot the first year, it’s really busy. The second year I really branched out, so I was working with Ken and now we’re looking at a 10-year review. We called it our syphilis experience over ten years. Who is coming in for syphilis testing? Who’s getting re-infected? Who’s getting treated? Who’s completing treatment and who’s not? Who’s seroconverting and who’s not? People who are suppressed, who are virally suppressed, what’s there experience like? So, looking at it for a lot of different factors over the course of a decade, which – with the help of another individual named Tim Mensa who was tremendous in terms of analysing the data and really helped me take a look at it, we were able to find some interesting correlations between all those things. And really, not a lot of surprising things, it’s mostly young men who are coming in and getting syphilis and syphilis reinfections and what not. A larger signal in sort of black men in Boston itself. And then we saw that viral suppression was correlated with less incidence of syphilis. So, HIV positive folks – and I don’t know if correlation means causation by any means – but we knew that patients who were consistently biologically suppressed had less diagnoses than HIV positive folks who were not consistently biologically suppressed. And if that’s a marker of how they interact with the health care system and what not, it’s hard to say but that was an interesting finding right there.
SN: Were there any other interesting findings that surprised you? Either in that or the five-year review that you had done.
AH: Yeah, I think with the five-year review, it was interesting what we saw. Essentially it took 1.5 infections before someone seroconverted. And that for me, at least – I think looking back now, again, there’s been data that’s been able to replicate that too, but as someone starting out, I was like, “Oh, wow, that’s insane. That’s how high the risk factor of syphilis is for HIV infection.” And I didn’t realize that before. But yeah, it was a very interesting finding on that. We saw similar work out of the 10 review itself. What’s interesting now, and Doug who came and talked a few weeks ago did work on this took, syphilis and HIV have always been sort of cousins to each other, almost. They’re always traveling together within coupled infections. But with the advent of PrEP we’re seeing an uncoupling of this now. So, syphilis begets HIV but syphilis in the setting of PrEP doesn’t beget HIV. So, what we saw at least towards the end of our 10-year review was sort of, the proportion of syphilis infections at least in 2005, the majority of syphilis infections were actually HIV positive folks. We just saw a lot more in the HIV positive community. Versus by 2015, actually HIV negative, the population of syphilis diagnoses were majority HIV negative. Which was very different than 10 years ago. So even that is changing, and I think it’s due to PrEP.
SN: I’m curious – because I know Fenway serves mainly MSM –
AH: Yeah.
SN: – what those trends look like in women, because I’m remembering from research projects talking to women about getting diagnosed with STI after STI after STI because they didn’t know what their partners were doing, having no clue. It’s an interesting intervention pathway for PrEP
AH: Yeah. Women are seen at Fenway but yeah, it’s predominately MSM – a white MSM too. So, it doesn’t capture the entire populations. But it was a great experience and I loved it. I was able to do high resolution endoscopies and work in their anal dysplasia clinic as well. I did a lot of Hep C work in fellowship. Yeah, and then a lot of really interesting, complex HIV management. You know, patients that have been positive since the 80s and how to juggle these medications and get them on the simplest regimen and what not. That was, all of those experiences, I think were exactly what I wanted to get out of fellowship, and I hope I can bring that in some regard here too.
SN: Yeah. One of the things you had talked about, obviously, was this interest in teaching and mentoring in the field of sexual health. And I think with the advent of PrEP it’s become even more important because physicians have such a role to pay in patient’s uptake. So how do you in education teach nonjudgement in talking about PrEP and being more open with patients about… They may be doing more things that you think are sexually risky but if they’re on PrEP, those might no longer be risky.
AH: I’m a huge proponent of risk reduction. So, I think there will always be people who will say, “They can just stop having sex, they can just use a condom, they can stop injecting.” And while the ideal would be great, yeah, sure, safe sex – if everyone could adhere to condom use, that’s great! But then when I tell them, when we take a look at human history, of all the time that people have been having sex in human history, how much of that has been with condoms? How much of that has been majority with “you have to use condoms.” Think about that, decades. Two, maybe three decades. And why? Because an entire generation was decimated because of a disease and it took that pressure to change our behaviour. That kind of pressure that your entire generation is dead because of this virus that is transmitted sexually. People got the message and condom use went up. I get it. But that pressure has been lifted. Rightfully so. That pressure has been lifted. So now people are changing sexual behaviour again because that pressure isn’t there anymore. I’m not a huge proponent of fear tactics of getting people to do safe sex. I think patients and people respond much better to options. We have condoms available, we have PrEP available. We have other risk reduction. How to close your sexual network. How, if you’re going to have sex with multiple people, maybe you pick and choose who you’re having sex with. All of that is what I consider part of risk reduction counselling. The same is used in substance use disorder counselling. So, my husband’s a psychiatrist and we talk about this all the time. The Scott County Epidemic in 2015 was all because Gov. Pence did not believe in risk reduction. He thought that by doing clean needle exchange was going to propagate more drug use, which was asinine and was already debunked by multiple studies. And the New England Journal ended up doing a review, because after the CDC was called, they obviously kept track of every new diagnosis and as soon as they started a syringe exchange program, the rates of new diagnosis plummeted in Scott County. It’s super effective and the thing, you have to give people choices. Obviously, abstinence, not sexual abstinence, I don’t believe in that, but abstaining from drug use, sure. I would love for people who want are addicted and want to get sober to be sober and stay sober. And that’s a great ideal to think about but that’s not realistic. So, I think by giving them options, by giving them “here’s a needle exchange, here’s a safe injection site area, here’s Suboxone to mitigate the risk that you have.” And obviously once you, if you are interested in getting sober, we can help you with that too, but that’s not the only pathway that’s available to them. And I think – I’m excited for all the other PrEP studies to come out. Because I think it also gives people options. I think some people don’t like having to take a pill every single day, they either don’t trust what’s in the pill or they don’t like having to see a doctor all the time for it. So injectable PrEP, the ring, and I feel like, again, patients just respond much better when they’re given options vs just like, “you have to do this or nothing else.”
SN: I was in Spain last week.
AH: Oh, for HIV RFP?
SN: Yeah, and it was hysterical because someone had a study about PrEP and women and they presented ring, film, injectable and one other. And their findings were about a quarter of women liked each of them equally. Everyone just wanted options. We don’t do a good job –
AH: And that’s what we have with contraception, right? I think women appreciate the option of what works best for them, what do they like the most. And if they’re all equally effective, what does it matter to us?
Work with the Opioid Epidemic
SN: No, it’s very true. Speaking of kind of the opioid epidemic and the drug epidemic in the last few years, I noticed in your biosketch that you had put in an interest in that. When did you get interested in that?
AH: So, Boston is sort of the epicentre of the Northeast opioid epidemic, and I definitely experienced that a lot during med school. But I think in medical training, attendings are always like, “Oh, you don’t have to see them, they’re a really difficult patient.” And so, you’re kind of sheltered from that in medical training which I think is wrong and I’ll probably circle back to that. When I did my medical residency here in Chicago, in the city itself, it’s not a huge epidemic itself, there’s definitely a rural urban divide, in the Midwest at least. In the East Coast, it’s a huge issue in the cities. And so, I didn’t forget about it, but I didn’t brush up against it as much. And then when I went back to fellowship, one of my mentors framed it – by then, we’re at 2016, now we’ve blown up fentanyls on the map. It’s huge, it’s bigger in Boston than it was when I left for med school. And one of my – in my first few weeks on the ID service as a first fellow, I saw more endocarditis, more osteomyelitis, all due to injection drug use than I saw in the entire time in residency, the entire three, four years I was in residency. I saw some of these infections through injection drug use in the first two weeks of my fellowship. And one of my mentors in fellowship, he framed it in such a way – this opioid use epidemic is our generation’s HIV epidemic. The way we remember the providers in the 80s and 90s who took care of HIV patients and particularly those who did not will be the way we are remembered in the future, of those who took care of patients and those who actively chose not to. In Boston there’s a whole ‘it takes a village’ mentality. It can’t just be psychiatrists. There aren’t enough psychiatrist to treat everyone who’s addicted to opioids. And it takes everyone. It takes family doctors, it takes paediatricians, it takes OB GYNs, it takes OB GYNs. Boston has a huge – everyone was getting wavered for Naloxone. As ID fellows we got wavered. At the time we didn’t really have an addiction service on our floor so it would be so frustrating because you would see these patients in the hospital who have a pretty morbid infectious complication to their addiction to drug use, whether that be a heart infection, a bone infection, a lung infection, an eye infection. And we can treat the infection, sure, that’s not the problem. But they would get discharged with no real plan of how to address the underlying issue. We’re essentially just putting a Band-Aid on the problem itself. So, yeah, what they ended up doing – the ID fellows, we would obviously see these people on the wards, it would be easy for them to follow up with us because we had clinic availability and we were often seeing these patients for whatever reason on a weekly, biweekly or every three weeks kind of basis. And so, we got wavered in Suboxone, we would induce them in the hospital and then see them and then be able to at least be a bridge until they could see a mental health provider and what not. And that entire thing sort of flipped a script for me that I was just like, “Okay, I get it.” This is an epidemic and we can’t just sit back and say, “Not my problem. I’m not a psychiatrist, this doesn’t affect me.” Because it does affect you. In Boston, I saw 20-year olds die of endocarditis, which is insane. But yeah, I think – so someone was telling a statistic, and you’ll probably have to fact check this. The number of people dying of opioid overdoses is now higher than the number of people who died of AIDS at the height of the epidemic. I mean, it’s unconscionable that people in the medical community would still be like “Oh, but I don’t think we need to see those patients. Oh, they ‘deserve’ it, why they don’t just stop using?” These are all things that people heard 20 years ago, this BS that we think of as “how could a doctor say that to an HIV positive patient.” It’s happening right now, and people aren’t addressing that. So that’s where the passion really comes from, so we’re going to be starting a Suboxone clinic at Howard Brown 55th because I found out there are no major Suboxone providers on the South Side. So, Howard Brown 55th, Howard Brown 47th will both be having Suboxone providers. And hey, I get it, this – there’s a huge urban rural divide in the Midwest of where the OUD epidemic is, and I don’t know. I will open the clinic and see who comes. But there at least should be resources on site for these patients. I know Haymarket is the huge detox center on the West Side and they see a lot of people. There definitely is a need in the city. So, we’ll see who we get filtered into our system and what not.
SN: That’s incredible. If you had anything you wanted to add on at the end, but other than that, we’re done!
AH: Yeah. This was great. I’m super excited to see where this takes me. As I said, it’s like sort of everything I was really interested in and passionate about in my entire training so it’s really exciting to be able to flesh it out.