In the 18 months that Tavell L. Kindall, D.N.P., APRN, FNP, a board-certified family nurse practitioner, has worked at St. Thomas Community Health Center in New Orleans, he’s increased the viral suppression rate of the center’s HIV-positive patients from 65% to nearly 90%. To compare, the Ryan White HIV/AIDS Program’s goal and the national average are both approximately 85% suppression.
I spoke with him about how he did it. He attributes his success to building relationships with his patients, educating patients on the facts of HIV and available treatment to help lessen the stigma, and persistently following up with his approximately 100 patients per month on treatment management and adherence.
Larry Buhl: Please describe your practice.
Tavell Kindall: Thomas Community Health Center is an FQHC, a federally qualified health center. Primarily, the patients have limited resources and high poverty level. Primarily minority, with majority African American and a growing number of Hispanic patients with various nationalities. Majority are living with HIV, but because I do other infectious diseases, not all have HIV. Some have hepatitis, or late tuberculosis. I’m carved out as an infectious-disease provider.
I started at this clinic in September 2018. Prior to that I was at a community-based organization in northeast Louisiana who decided to start their own HIV clinic after the charity health system that we have in the state got privatized. The majority of my newly diagnosed come to me internally. All of our primary care providers screen for HIV with new patients. They may have been out of care, and I’ve had a lot of success with those returning to care. They share with the primary care provider that they have a history of HIV, and then they’ll be referred to me. Some find us through social media, by looking for HIV providers in the area. Some word of mouth. Some I cared for in northeast Louisiana. They have followed me here.
LB: They commute from across the state to see you?
TK: I have a cohort that commutes. Because if they’ve lived with HIV for more than two years and don’t have any comorbidities, they don’t want to share their story with anyone else. When I relocated they asked to continue to see me. I usually see them twice a year, because they are well otherwise and they have a primary care provider where they live, and they come to me to manage their HIV. They see me on a Friday typically, then make a weekend out of it in New Orleans.
LB: You’ve achieved greater viral suppression in that group, to 90%. How did you get there?
TK: When I arrived, I asked the medical case manager to pull a list of all patients with viral loads greater than 200. So we contacted each of them. I introduced myself and asked them individually to have a conversation with me. I sat down with them and a medical case manager and the director of nursing, who has experience with people living with HIV. The three of us asked questions to find out why they were not suppressed.
The majority were having adherence issues to antiretroviral therapy. We talked about the ways they could remain adherent, from simple things like pill cases or key chains to keep pills with them. Some were on regimens that were [out]dated and having to take a lot of medications. We talked about options to modernize their therapy on single-tablet therapy. We individualized their treatment.
We tried to get to know them and their lifestyle, the type of work they do, and identify anything getting in the way of adhering to therapy. I was pretty aggressive in urging them to return. I want to show them that if they take the meds consistently they’ll see a dramatic decrease in their viral load. I talked about how getting them undetectable translates to their overall health and preventing serious health consequences from advancing HIV.
LB: Did primary care doctors not tell them all this?
TK: They hadn’t come to see the primary physicians. I have also been able to handle their primary care needs too, because some would rather have one who can do it all. I’m a family nurse practitioner, so not only can I manage their HIV, but I have access to my other colleagues if it’s something I can’t control.
LB: Your patient load must be high.
TK: The first six months was rough. But now that I have so many people undetectable, it’s manageable. I’ll share with you one patient who had a bad relationship with his provider. He said the doctor didn’t treat him right and talked down to him. And because he had been living with HIV for some time, he had experienced some of the old antiretroviral therapy that had side effects. He told me, “You’re the first provider who just wanted to get to know me and have a conversation.” I said, “I want to get to know you as a person. You just so happen to be living with HIV. I can’t ignore other things going on in your life. It starts with you.” We established a good rapport. I started him on a single-tablet regimen.
When he came back to me a few weeks later, he said, “This isn’t working, because I don’t feel anything.” I asked him what he meant. He said, “When I was on the other meds, I got nauseated, sometimes I felt drunk.” He told me all the adverse side effects people had on the older meds. I said, “Guess what, we have better drugs now, and I wanted you to make sure you understood that when we started.” He was like, “Oh my god, if I had these 10 years ago, my life would be totally different.”
LB: So the secret is being honest and comprehensive and … compassionate?
TK: One, being nice to people goes a long way. It helps to develop the relationship. The meds will do what they do, but in terms of helping patients self-actualize, that requires you as a provider to get a good relationship and rapport. Patients have told me all kinds of awful things about providers. A lot of people fell out of care because of that. They hated the providers they were seeing. And some patients love their providers, and that makes a real difference. I’m not always successful, I have some challenges, but the majority, I have a good relationship with.
But I’m not a physician. I’m a nurse first. There is a difference. We can diagnose and treat, but fundamentally we are taught to care. I find that nurses have a little more creativity and success in doing that, because the nursing model is different.
LB: Maybe the primary point of contact for people with HIV should be a nurse practitioner?
TK: In some states, the NP is it in terms of providing care—they have full practice authority. Louisiana is not one of those states. They must have an agreement with a physician to do what they do. I manage their HIV. My patients don’t see a physician unless I refer them to one. Even the treatment-naive, I manage it and we take care of it.
LB: What does your clinic do regarding prevention?
TK: My official title is director of HIV prevention and treatment. I have a small group of patients that I have on PrEP [pre-exposure prophylaxis], but the majority of my role is to empower and educate and support the primary care provider to give prevention medication. If someone comes in with an STI, we will treat that, but we will also say, “Look, you are at risk of HIV acquisition, so let’s talk about PrEP.” We have a PrEP navigator, and we’re very fortunate in this state that Medicaid is expanded, now, so it’s not such a barrier or issue to access PrEP. That was one of the first things our governor [John Bel Edwards] did. If they need Medicaid, we can get them approved. We are easily able to get them on what they need. I can’t imagine being an HIV provider in a non–Medicaid expansion state.
LB: What else would you like to share with colleagues across the U.S. regarding HIV prevention and treatment?
TK: We have the research that supports undetectable equals untransmittable. The challenge is finding those people who are living with HIV and don’t know it. We are still having challenges getting primary care doctors to screen for HIV. I ask all practitioners, anyone with the ability to screen, please screen.
LB: Why don’t they screen?
TK: Some providers are unaware of what it takes. They think you need a long counseling session. In our clinic when people come in for the first time, they sign a consent, we establish labs including HIV, and get all those things done the same day. Unless they say, “Don’t screen me for HIV,” then it’s done. Some [providers] are worried about getting reimbursed for the testing. Some said, “I’m afraid to tell patients they have HIV.” Well you’re going to have to get that skill. Reach out to the resources, the department of health, there are continuing education trainings, sexual health history, to get you comfortable in asking about that. [Providers] share life-altering diagnoses all the time. So why be afraid to tell someone they have HIV? It’s their own fears, and they have to own that and get comfortable in doing it.