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Interview

Why NYC's New HIV/AIDS Chief Took the Job -- And What He Plans to Do With It

August 7, 2014

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Who's the Treatment Action Group executive director, and a former ACT UP member.

Exactly. When he got wind that I was contemplating it, I got an email with the subject line "History is Calling," and it was this very inspiring email -- saying "this is what it's all led to." He was an external person saying the same thing that I had been saying to myself. I actually probably value Mark's opinion more than the little voice in my head, because he's been through all of this. So that was really inspiring to me, to get someone who I personally am inspired by, in terms of the activist role that I've had in the past, to say to me, "You know what? Step up and do it." So that's a big deal.

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Same goes with Paul Sax. Paul Sax is a clinical mentor and so, when Paul said, "This is a good thing. What do you think?" And I told him what I thought, and he said, "Sounds like the right thing." He's one of the people whose opinions I really value. So the combination of having someone who is a role model in the activist world and someone who is a role model in the clinical universe say to you the same thing that matches the voice in your head, says that it's worth taking the risk and seeing what it's all about to be a public health official in the largest Department of Health in the epicenter of HIV.

I've always perceived you as a little bit of a cowboy, thinking about your work in sex venues, and how you grabbed on to the meningitis outbreak and just said, "I'm going to jump in, and we're going to do something about this." Your predecessors in these roles probably wouldn't be labeled as kind of a cowboy, or a cowgirl. I'm not saying this in a critical way, but they have a different style than you.

Right.

When I think of you, I'm like, "Wow. He really does public health." You just don't talk about it as theories -- about "stages of change," and all the stuff that we think about when we go get our degrees in public health; you actually go do it. And you do it at 3 o'clock in the morning. Because you go to where people are.

Government tends to be a little conservative -- or at least, most people perceive it to be. What is your vision for running this bureau in a culture that may not be used to this cowboy kind of vision of how we look at public health?

First, when I think of cowboy, I think of people who are doing things with no evidence base, and just doing it from their gut. So I feel that -- though I am somebody who moves from theory to action fairly quickly -- most of the things that I've done have tended to follow lines of evidence. And that's the public health human in me.

I feel that the city has made a pretty significant vote of confidence in somebody who is willing to move from theory to action very quickly by offering me the job. I have a learning curve, for sure, in terms of how to work within government. That's going to be something that I'm going to learn and for that, thankfully, I have really good mentors already at the Department of Health to guide me through.

The bureau is great. The department is great. Dr. Bassett: amazing. Dr. Varma: amazing. So these are people I'm going to ask questions, as we go along. But ultimately, I think that my job there is to move theory into action as quickly as possible. So that's what I'm landing to do as my charge.

Government may be slow, and I'm going to learn some of the limits. But then, ultimately, what drives my actions is that I always try to do what I think is the right thing, based on the evidence, and based on what's good for the community at risk, or the community living with HIV.

So that's ultimately my answer, which is: I'm going to, I'm sure, make some mistakes, in terms of government. But I'm not going to make a lot of mistakes, in terms of doing the right thing.

You were interviewed by The New York Times minutes after probably you were offered the position.

Right.

And the headline for that particular article said, "Credibility Among Gay Men Gives Leverage to New York City's New Chief of HIV Prevention." That is not exactly correct -- that's not all you're doing. You're not just the chief of HIV prevention in that Bureau of AIDS. You are definitely over HIV prevention, but you're also over care and treatment. There's an epidemiology unit. There is housing for people with HIV that's embedded within the bureau. Talk to me a little bit about your ideas. Let's start with care and treatment.

Care and treatment is also a little bit of a misnomer, because you're not funding medical care; it's social services that the bureau funds.

Right.

Now that you are in the seat where you could make some changes, are there things that you've already thought about, like, "Wow, if I could change this, I would do it?"

The background that I'm coming with isn't just an HIV, first of all, prevention background. I'm coming from the perspective of a medical director of a really big HIV clinic, and also as someone who's done HIV care for years and years, both within a city system, and in a more traditional health care system -- not an HHC facility, not a city facility. So I feel that we've already had important conversations about some of the social services and some of the main issues that are facing people living with HIV in the city that we need to address.

One of the most important ones has to do with the people who are not engaged in care. I mean the people who are, frankly, at risk of dying. There's a lot that the Department of Health already has in terms of infrastructure to be able to assist clinics to get people engaged in care. One of the things I really want to focus on is ways to look at the field presence of the Department of Health, not only for new diagnoses, but potentially for people who are just missing.

We're in this sweet spot from the perspective of policy, where we have the ability now to use surveillance information with clinicians to figure out the best way to identify people who need such services. So that's going to be one of the things that I want to focus on -- to look at the population of people who are coming in and out of the hospital who have been diagnosed with HIV, who have low T cells and detectable viral loads, and who aren't connecting to the system, to really figure out ways that we can re-engage them on their terms.

There may be a lot of ideas behind that. I'm going to develop that as I land in the bureau. But I've already started thinking about some ideas about how to make that presence bigger. So that's one.

Housing is critical -- I guess I'm transitioning into housing.

That's still kind of care --

Right. I think housing is critical. We're going to have to understand better what the goals are of HIV housing, like HASA and HOPWA and all of that, and figure out what its role is in the broader population. And what the definitions are for people who utilize those services and who get those benefits. I think it's really important for us to scrutinize and see what is the optimal use of that. So I'm just starting to scratch the surface of housing in the Department of Health. But the good news is that there are a lot of smart people who have worked in this area at the Department of Health for years and who I'm going to be able to access to address some of the barriers that I felt as a consumer of these services.

From the perspective of a clinician on the ground, I think that there are definitely some barriers, and some of those barriers actually impact care, in terms of getting people into housing. So it's going to be an area of emphasis but, again, a learning curve on that. Because administratively, I'm not on the intake side of that; I'm on the outtake side. So I'm using those services as a provider, and have definite insights into how that goes.

One of the interesting things about the bureau is that there is an element of silos that happens -- just like with, I'm sure, every organization that we've ever worked at in our lives. So, prevention is kind of over here; care is over here; epidemiology is over here.

There are activists in New York City who wonder, "Why doesn't the Prevention Planning Group ever meet with the Ryan White Planning Council group? And shouldn't they be talking?" I mean, if for no other reason, we now have PEP [post-exposure prophylaxis] and PrEP [pre-exposure prophylaxis].

I have a very philosophical answer to this, which will then, I hope, engender conversations at the Department of Health that will lead to exactly what you're asking. Philosophically speaking, one of the things that I believe is that there is no differentiation between HIV prevention and HIV care. I think it is the same thing.

What I mean by that is, the tools that we use in HIV care are exactly the tools that you need in HIV prevention to prevent HIV infections. So, what you use to keep people healthy with HIV -- mental health services, substance abuse services, housing services -- that's all one continuum. And so, philosophically speaking, though the Department of Health does not fund care, per se --

Medical care.

-- medical care, per se -- it's going to be really important for us to look at those services and try to provide the services needed to people living with HIV; but also to make them HIV-neutral, and really look and see how we can spread those in a way that actually also addresses the fact that the same problems that led to HIV infection, and that continue to be a part of people's lives, are also the issues that can be prevented to avert HIV infection.

The idea of really breaking down the silos between prevention and treatment, and services focusing on people living with HIV, is going to be key. And I think, in lots of ways, epidemiology kind of lives in the middle.

And so, if you design this in a way, and really focus on looking at the bureau and say, "How can we break these silos down and have it all center on epidemiology, that is going to be the key. Epidemiology is a common strain that connects many of the silos included in the bureau or any other large HIV-associated endeavor. Recognizing the common strain of data-based decision making in both treatment and prevention, as well as the synergy of the tools in both "silos," implies a potentially HIV-neutral approach to HIV. I think that's going to be the key -- which is to say, we have this amazing data coming in from people living with HIV; we have the potential for great data coming from people who are at risk for HIV. You've got this epidemiology core and this powerful amount of data that can change how things are done by aligning resources to the goal of controlling HIV/AIDS without regard to a treatment or prevention silo. The lines are blurred.

Prevention groups and treatment groups need to coalesce -- at least, in some conversations.

I'll take it back to the clinic: When I meet a patient who is at risk for HIV, the conversation I have with them is barely different than the one I'm having with the person who has HIV. It is the exact same conversation. But sometimes I'm limited to what I can do. I don't have access to some of the services for them.

So I think we have to look at that critically and say: If we're creating this treatment cascade for New York, are we missing a bar? Is the bar of people who are at risk missing? And how can we maintain that bar of people at risk and deal with them without compromising our eyes on the prize? Which is not that treatment is just treatment-for-prevention, but treatment's for treatment! Treatment saves lives! I remember. I saw that. I know. And so, I feel like it's going to be an interesting balance of how to [not only] homogenize the experience into an HIV-neutral zone, but also maintain the important services for people living with HIV.

Again, I'm landing there with that philosophy and, hopefully, a lot of political will above me to do that. But, you know, treatment needs to be central; and prevention needs to be central, too. And I just think that they are the same, in so many ways.

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