An Interview With Edward Machtinger, M.D.
Edward Machtinger, M.D., is a professor of medicine and the director of the Women's HIV Program at the University of California, San Francisco.
When treating an HIV-positive person, it's already a fair amount of work, and sometimes quite the balancing act, just to focus on the numbers: CD4 count, viral load, lipid levels, renal markers, and so on. But for a massive number of people with HIV, how well they are doing can't solely be measured numerically. The extent to which life trauma affects their health is a major factor, and it can seem daunting to find the time, resources, strategies and confidence to address the impact of profoundly affecting, often-disturbing and frequently ongoing trauma.
Edward Machtinger, M.D., has devoted his career to innovative work with marginalized and vulnerable people living with HIV, and has collaborated with researchers, providers and advocates to develop a scalable model of trauma-informed primary care for women living with HIV that has proven helpful for patients and providers alike.
TheBodyPRO.com recently interviewed Dr. Machtinger, who is a professor of medicine and the director of the Women's HIV Program at the University of California, San Francisco (UCSF). He spoke with us about his research, clinical experiences and collaboration with advocates to create this model, and shared thoughts and resources for its implementation.
Awakening to the Impact of Trauma
Let me start out by asking your background as a provider, how you came to this project, and how you came to understand the importance of trauma-informed care.
I first decided to go into medicine because I was a young, gay activist in college in the mid-'80s in New York City, as the early HIV epidemic was really exploding. I thought of medicine as a way for me to be involved meaningfully in the epidemic. I had, at that time, hoped to run a small, creative, innovative program for vulnerable or marginalized individuals living with HIV.
Ultimately, that's where I ended up. I went to medical school at Harvard, and I did my internship and residency in primary care internal medicine at UCSF, and started working as an HIV primary care specialist right after residency. I run a Ryan White-funded program for women and adolescents living with HIV, including transgender women. The program was among the first in the country specifically designed for women living with HIV.
We got our first grant for the program in 1993 after we realized that the women being seen in the general program weren't doing very well. They would come into the program and most people who were working there were gay and white. Most of the other patients were gay and white. And the women were really different. Most were women of color. Many were poor. Very few of them were out. And the experience of being in the clinic just further reinforced the idea that it shouldn't be happening to them, that something was terribly the matter that they had HIV, and that they were really unique -- when, in reality, there were more and more people just like them getting HIV.
What would happen is, especially because they weren't out about their HIV status, almost to anybody, they wouldn't go get the services they needed that we referred them to -- the gynecological services, social services, mental health services. And so we decided to create a clinic that was a one-stop shop for women and girls living with HIV that has since become the norm, or the model, for Ryan White care services for women across the country.
My awakening to the issue of the impact of trauma on the lives of our patients came when one of our patients was found floating in the San Francisco Bay. That was a patient who we knew and loved very much.
We also knew that she was experiencing horrific domestic violence from her partner, and did everything we could as a clinic and as a community to help her get safe. In the end, that didn't work; he lured her away from where she was staying and murdered her, likely because he realized that she was really going to leave him.
We convened a group of all of the people in the city -- approximately 30 different providers -- who had worked with her, to learn from her death. From those meetings we realized that our clinics, despite having really exceptional HIV services and medical services, were really not designed to help women heal from lifelong abuse and prevent re-victimization.
More fundamentally, we realized that there was a mismatch between the treatment we were providing our patients and the healing that they really needed. From that meeting, we dedicated ourselves to understanding the intersection between recent and past abuse and the health outcomes of our patients.
Recent Abuse Linked to Poor Outcomes, Antiretroviral Therapy Failure
As you came to have an understanding of the impact of trauma on your patients' lives, how were your patients doing? And what did you come to understand were the ways your clinic had to address trauma in order to make a difference in the HIV care continuum?
The first things that we did were two studies that looked at our patients, and then looked at women living with HIV across the country. Amongst our patients, we did a study looking at detailed behavioral and health data that we collect during intake interviews for our prevention-with-positives program. We looked for factors that were associated with core health outcomes amongst our patients.
"Even among [our patients] who have an undetectable viral load, the vast majority of the patients, from our perspective, are doing quite poorly."
We found that those patients who reported recent abuse were over four times more likely to be experiencing antiretroviral failure. And that, to us, was totally startling. We also found that over half of our patients report active depression. Forty percent of our patients are actively using crack cocaine, methamphetamine or heroin, and the vast majority of them are not out about their HIV status -- many not even to their families or their intimate partners.
If you look at the treatment cascade, our patients in general appear to be doing exceptionally well compared to the national rates: 91% of our patients are prescribed antiretroviral therapy, and 85% of those have an undetectable viral load. But even among those who have an undetectable viral load, the vast majority of the patients, from our perspective, are doing quite poorly. As I mentioned, over half are depressed. Almost half are actively using hard drugs. Very few have supportive networks of friends to help them through difficult situations, and help them avoid abusive partners, and help them be successful with their life and health goals. We hypothesized that, for many of our patients, not being out about their HIV status or histories of trauma was a key impediment to making real friends and creating a support network.