Johns Hopkins AIDS Service
Patient Care -- Education -- Research
A Multi-Disciplinary Program
Dedicated to the Treatment and Prevention of HIV Infection
The Hopkins AIDS Care Program was initiated in January 1984 with the opening of the Moore Clinic for patients with HIV infection. The program has subsequently grown in numbers of patients and providers, and has now matured by the development of a full care network. It was organized in 1992 with the pro bono assistance of an executive (bank president) and a professor of business. The service was subsequently structured with the following service categories:
- Inpatient Unit: This is a 21-bed AIDS inpatient unit at Johns Hopkins Hospital under our direct supervision for medical care services. The "AIDS ward" was established in 1986 and averages 700-800 admissions/year, primarily patients followed in our clinic. The number of admissions has been maintained at this level even after protease inhibitors, but only because we expanded the number of patients served in the outpatient clinic and changed admission criteria to include all HIV-infected patients (rather than exclusively those enrolled in the Moore Clinic). The service has an attending from the ID Division, an ID fellow who serves as chief resident, three Hopkins house staff and one or two subinterns or students. The fellow is the "gatekeeper" with the attending as backup.
- The Moore Clinic: This is the outpatient unit supervised by the Hopkins AIDS Service that currently consists of 11 examining rooms, four registrars, two phlebotomists, and an outpatient treatment center. The clinic has approximately 20,000 patient visits/year and is staffed by eight midlevel practitioners (nurse practitioners and physician assistants), 18 primary care providers primarily from the faculty in the Division of Infectious Diseases (four are paid by the service and work > six half-days/week; most of the rest provide volunteer service for one or two half-days/week). There are seven major specialty services: GI, neurology, psychiatry, gynecology, obstetrics, ophthalmology and dermatology. The Moore Clinic is the "centerpiece" of the AIDS Service which currently follows over 2,000 patients in various stages of HIV infection. This clinic has been developed to provide specialized services tailored to the idiosyncratic needs of patients with HIV infection. Services available within the clinic are subspecialty consults, counseling, case management, social work service, induced sputum, pulse oximetry, aerosolized pentamidine, infusion services, lab services (viral burden <48 hours, cryptococcal antigen -- 20 minutes, etc.), endoscopy, line placement, etc. An outpatient pharmacy in the clinic is under construction.
- Social Work Program: Includes six full-time social workers who provide case management and other social work services.
- Bayview Special Care Unit: Johns Hopkins-Bayview Medical Center is a chronic care facility for HIV/AIDS patients located on the campus of our sister institution. This facility has 21 beds for patients with HIV infection, the providers are from the Hopkins AIDS Service (1.5 FTE midlevel providers), and a medical director (0.3 FTE) from our group. ID fellows and attendings "cover" this service while attending at Bayview on the ID consult service.
- Cinical Research Program: Includes the Hopkins ACTG as well as multiple pharmaceutical-supported clinical trials (revenue of about $2.5 million/year). This is obviously important for gaining access to new drugs and offsetting some clinical, laboratory and drug costs.
- Moore Clinic Database: A computerized program was established in 1989 by R. Moore and R. Chaisson to collect information regarding resource utilization including laboratory data, hospitalization, events (complications), etc. A somewhat unique facet of this program is that it included Medicaid payment data prior to the 1115 waiver. The reason it is unique is that this requires informed consent from participants since it includes patient-specific data; informed consent was obtained from 97% of our patients. The database has been the source of important information regarding resource utilization, cost of care, frequency of complications and comparative data across risk categories and other patient variables. Technical support includes 5 FTE chart abstractors and a sophisticated analytical component. The required funding is about $400,000/year. The database was instrumental in providing the information necessary to convince the Hopkins Administration that we were a good risk for managed care since our costs were substantially lower compared to the state averages as indicated by the historic rate data from Maryland Medicaid. The database has been the source of about 60 publications.
- Specialty Services: An important inclusion in the Hopkins AIDS Service is multiple specialists who provide the expertise of their discipline to patients with HIV infection. These services and the approximate number of outpatient consults/year are: gastroenterology (170 visits/year), psychiatry (1500), neurology (450), gynecology (300), dermatology (400) and ophthalmology (860). All but ophthalmology provide service in the Moore Clinic.
- Network Development: The model of HIV care services in the Hopkins AIDS Service includes contractual arrangements with HIV care services at off-campus locations including the two STD clinics operated by the Baltimore City Health Department (600 HIV-infected patients), and six county health departments largely in Central Maryland (200 patients). The outpatient care in these facilities is conducted on-site at the local clinic (STD clinic or health department clinic) and it is supervised by a Hopkins physician and a PA who attend these clinics. Hopkins HIV specialists and the Johns Hopkins Hospital are used when tertiary care is required. These affiliated clinics do not have tertiary care facilities and are not able to qualify as an MCO under the 1115 waiver. Thus, the Johns Hopkins program represents the logical referral for continuity of care when these patients qualify for Medicaid.
- Outreach: This component of the Service is directed by one FTE African-American community leader. Responsibilities include community linkage through the Hopkins "Historic East Baltimore Community Alliance," local meetings, public relations, liaison with HIV service organizations and administration of the Community Advisory Board composed of patients and community leaders.
The importance of this network of services within the Hopkins HIV/AIDS Program is that it represents an integrated system in which one group of providers manages patients through all components of the system. The Hopkins AIDS Care Service now has about 82 FTE (excluding physicians) or 142 FTE if the Osler 8 inpatient unit is included. Representatives of each group defined above are represented on an Executive Committee that meets on a regular basis to deal with issues of mutual interest and assure coordination of efforts. Each component has a mission statement, budget, program definition and description of goals and objectives. There were two retreats to facilitate integration of services and long term planning. This organizational structure became important for managed care planning because most of the network required to deliver care within an MCO was already developed. Other services that required development were a pharmacy benefit manager, transportation, and a home care program. The extensive network development was an important factor in persuading Johns Hopkins Health System to support the AIDS Service as a high priority for institutional support in managed care.
A patient population of about 2,000 is served by the Hopkins HIV Care Service. Most are from Central Maryland and their demographics reflect the epidemic in Baltimore (Table 2). Demographics and risk categories show 76% of patients are African-American, 53% are injection drug users and 26% have an Axis-1 mental health disorder. The number with a CD4 cell count less than 200 is 38%. With regard to third party payor, 60% are Medicaid recipients, 34% are "no pay" and 6% have some form of commercial insurance. Approximately 5% of patients are homeless, but many more have no stable residence. There is a special hematology-infectious disease clinic for patients with hemophilia and HIV infection with a total enrollment of 22.
Table 2: Patients Served at the Moore Clinic
Clinic census (CY 96)
Number clinic visits (CY 96)
No. new patients (CY 96)
Sex: Male -- 68%; female -- 32%
Race: African-American -- 81%; Caucasian -- 19%
Risk: IDU -- 50%; gay male -- 18%
Payor source: Medicaid -- 60%; "no pay" -- 34%; Commercial: 23%
Latest by Johns Hopkins AIDS Service
Cytomegalovirus (CMV) retinitis is among the most common opportunistic infections in patients with AIDS \[Trans Am Ophthalmol Soc, 93, 623, 1995\]. The incidence of CMV retinitis is approximately 10% per year in patients with CD4 counts <100 cells/mm...
Introduction: A number of endocrine abnormalities have been reported in people infected with HIV. Among these, hypogonadism is well described, particularly as men progress to AIDS and in those who are wasting. Testosterone has both anabolic and andro...
Up to 45% of patients with AIDS develop CMV disease in the era of PCP prophylaxis, usually when their CD4+ T-lymphocyte count drops below 50 cells/mm 3. CMV retinitis accounts for 80-90% of cases of end-organ CMV disease. There are now two drugs appr...