20 years later, H.I.V. Center still has its doors open

By Duncan Osborne

Matt Baney joined Saint Vincent Catholic Medical Centers in 1992. He remembers when the prospects for an H.I.V.-positive person were grim and healthcare providers had little to offer such individuals.

“At that point, we were housing up to 200, 220 patients per day,” said the director of the hospital’s Comprehensive H.I.V. Center. “Patient stays were very short. Patients came in with P.C.P. pneumonia, toxoplasmosis, whatever it might be. … Unfortunately, people died rather quickly.”

Dr. Antonio Urbina, the H.I.V. center’s medical director, did his residency at the West Village hospital from 1992 to 1995.

“You would go to the emergency department — basically stretchers wall to wall,” he said.

In 2008, the Comprehensive H.I.V. Center celebrated its 20th anniversary and a dramatically changed landscape for people with H.I.V., the virus that causes AIDS.

In 2007, the center, with a staff of 85 and an annual budget of $7 million, saw more than 5,000 patients in 34,000 visits, and treated 1,500 inpatients. Some 800 of those patients were undocumented immigrants, predominantly from South America.

The hospital paid for some of that care itself because Medicaid and Medicare, the government-run health insurance plans, generally do not pay for services for undocumented immigrants.

“It’s a very limited amount of care that they are eligible for,” said Baney, referring to the undocumented immigrants. “We do a lot of charity care because a lot of our patients are homeless,” he added.

That 80 percent of the center’s patients have an undetectable viral load, which shows their anti-H.I.V. drugs are working, is remarkable given the population it serves.

“These are patients that have a lot of other co-morbid conditions,” Urbina said. “Thirty percent are co-infected with hepatitis C; a fair share of them have either mental illness or substance abuse issues or both. These are not your Park Avenue patients.”

What is most striking, in comparison to 1992, is that the H.I.V. Center is now offering cutting-edge services and treatments for people with H.I.V.

The state Health Department will spend $290,000 a year for five years to have center staff, along with the Montefiore Medical Center in the Bronx, train emergency departments across the state on providing post-exposure prophylaxis, or PEP, to people who have been recently exposed to H.I.V.

“It’s really to increase awareness about PEP,” Urbina said. “I think that’s one of its main goals, and to educate emergency departments on how to provide PEP.”

The protocol is a month of treatment on three anti-H.I.V. drugs. The regimen must start within 72 hours of the exposure to be effective, so doctors must be taught when to recognize that PEP is needed and to act quickly. The center handles 15 to 20 PEP cases every month.

“The majority are men who have sex with men, but we’ve had a lot of sexual assaults and we’ve also had persons that identify as heterosexual,” Urbina said.

The center is also working with the city Health Department since the department’s May implementation of pooled P.C.R. testing, an H.I.V. test that can identify individuals within days of their first becoming infected.

A standard H.I.V. test detects antibodies to the virus. While the tests are highly sensitive, individuals produce H.I.V. antibodies at varying rate, and some may go undetected with a standard test as much as a month after first becoming infected.

In the more-accurate pooled testing, the Department of Health takes blood samples from people testing at four — and soon to be six — of the city’s sexually transmitted disease clinics. The blood samples are mixed and tested for minute amounts of H.I.V.’s genetic material. When a batch tests positive, the samples are tested individually to find the infected person.

“At this point, about 70 percent of the H.I.V. testing that we would be doing is being subjected to pooled testing,” said Dr. Susan Blank, assistant commissioner in the Health Department’s Bureau of Sexually Transmitted Disease Control. “It is being done in high-volume clinics with highly at-risk persons.”

These newly infected individuals are referred to the center for possible treatment and counseling — especially about changing their sexual behavior.

“When they identify somebody [with a new infection] out in the field, they’ll call us on our cell and we will arrange for that patient to be seen that day,” Urbina said. “We definitely offer them starting on anti-retroviral therapies. I think it’s still debatable whether there is a clinical benefit to starting patients on anti-retrovirals during acute infection.”

Blank said, “It has been a really terrific partnership. It’s really seamless for the patients. St. Vincent’s is especially well equipped to handle people in this stage of their infection. Their help has been essential in our ability to do this.”

People who are newly infected are highly infectious and, because they do not know they are infected, more likely to infect others if they have unsafe sex.

“You identify those persons in a timely manner and get them out of their sexual networks,” Urbina said.

The Health Department began sending patients with these acute infections to the Greenwich Village center in August.

“They’ve identified 16 cases of persons in acute H.I.V. infection,” Urbina said. “The vast majority are young men who have sex with men.”

These new technologies come as new H.I.V. infections are declining in every population in New York City except for men who have sex with men. St. Vincent’s is seeing more new infections in young New Yorkers.

“Last year, we identified six new adolescents,” Urbina said. “This year, to date, we’ve identified 19.”

The 19 fall broadly into two groups.

“One are the young men who have sex with men, and those have kind of the traditional risk factors, substance use, lots of sexual partners, unsafe sex,” Urbina said. “Then we’re seeing another group of youth, and that’s about six of those 19, where they’re homeless and typically they’re acquiring H.I.V. from older men, and by older I mean 10 to 20 years older.”

While the center can point to any number of success stories among its patients, these new cases, sadly, mean its doors will remain open for some time.