Episode 2: Crystal Hodge, PharmD, BCIDP

Dr. Hodge is an Associate Professor of Pharmacotherapy with the University of North Texas Health Science Center, College of Pharmacy in Fort Worth, and practices as an Infectious Diseases Clinical Specialist Pharmacist at the University of Texas Southwestern Medical Center in Dallas.

Transcript

[00:00] Introduction

Welcome to another episode of the Red Ribbon Report, where we hear from real people with real stories and real perspectives from the HIV workforce. I am Wari Allison, your host for today's episode, and I am the Vice President of Health Policy at the University of North Texas Health Science Center at Fort Worth, and the Executive Director of the Center for Health Policy.

I am thrilled to have you join us. From HIV care professionals to researchers to patients, our goal is to let our guests tell their stories and take us on a journey to give us a better understanding of their lives and experiences. A major objective of our conversations is to give future health care professionals insight into being part of the HIV workforce.

Today, we will continue our conversation with infectious disease pharmacist, Dr. Crystal Hodge, who shared her incredible journey with us in our previous first episode. If you missed it, please be sure to check it out for her deep dive into her personal and professional path of her HIV career. Before we continue our conversation, I want to take a moment to thank you, our listeners, for being here with us today.

[01:16] Why is HIV education important in terms of HIV care and prevention? 

Dr. Allison:

So let's get started. Dr. Hodge, thank you for joining us again. In this episode, we're going to shift the focus a little bit to two critical topics: HIV education and the HIV workforce shortage across the United States. 

So first off, why is HIV education important in terms of the HIV care continuum, and how does it contribute to the national and the HIV Epidemic EHE initiative goals?

Dr. Hodge:

Hey Wari, it's great to be here again. So for the End the HIV Epidemic goals, there's four main pillars, right? So really quickly, those are diagnosing as early as possible, treating people rapidly and effectively to reach that sustained virologic suppression, preventing new HIV transmission and then responding to potential HIV outbreaks. So those are our goals to try to End the HIV Epidemic.

Some of the more ambitious goals that I really hope we meet is that we want to reduce the new- the number of new HIV infections by 75% by 2025, which is basically here, and 90% by 2030. And we have several other goals. But you also asked why it's important. And one of the reasons why it's important to me is because I work in the South, and we have a lot of people living with HIV here in the South.

About 49% of new HIV infections are currently residing in the south, which is a pretty big deal. And then another piece of why it's important and why education in particular is important, is because we need to try to prevent new HIV infections. There's been some changes in how PrEP is being monitored, but some of the most recent data is from 2022. And in that data, it actually suggests that only about 36% of people who are eligible for PrEP actually were prescribed it. That's a really low number. It is an improvement compared to late 2019, and it has increased, but it's still a really low number. And so increasing education kind of hopefully increase access to PrEP as well as people who are being offered PrEP. And then obviously the treatment side as well. 

Dr. Allison:

I'm always outlining for our listeners who aren't familiar with the acronyms we use in this space. So PrEP is “Pre-Exposure Prophylaxis”, and it's a tablet and an injectable now that you can take to prevent HIV infection. 

[03:27] What common challenges or barriers have you encountered regarding HIV education among health care professionals?

Dr. Allison:

So moving on to my next topic of conversation. What are common challenges or barriers you yourself have encountered regarding HIV education amongst healthcare professionals?

Dr. Hodge: 

Yeah, I think one of the biggest ones, and we're starting to recognize this a little bit more, but I don't think that it's been fully outlined is that there's actually a decent, in my opinion and I'll caveat thought that this is my opinion, there is a decent amount of stigma or per view bias related to HIV. And what I mean by that is that if you're not in HIV, you kind of turf it to someone else, right?

So for example, if you are a primary care provider, then maybe you don't feel comfortable with HIV, so you're turfing it to the HIV specialists. And I think historically that was very accurate, right. HIV was kind of considered and is a specialty disease, but it was kind of considered like oncology where like you don't mess with HIV drugs, you don't mess with the oncology drugs, very much going to the specialists. And that's because a lot of our drugs were really toxic. They required a lot of nuance and to really require that specialty intervention. Now our drugs have gotten so good that it's really, in my opinion, more like a cardiology-type specialty, where you don't necessarily need a specialist unless you have a really complicated case. And so there's a lot of ability for our people who are virologically suppressed to not need HIV to be their primary care provider anymore.

And so maybe we should be leaning into our primary care colleagues for their multidisciplinary and multimorbidity expertise. So we have a lot more people who are with HIV, who are living longer, who have more comorbid conditions and multimorbidity. So maybe we can lean into having that more multidisciplinary care and involving more primary care and then when it comes to PrEP, like you don't see a cardiologist always for prevention of an MI, from Myocardial Infarction, right.

Like you have primary care that can help with that. Primary care can help with some of the screening and whatnot. So I think one of the things that we have to encounter or try to to overcome is figuring out where we can best utilize HIV specialist to make sure that we're really getting that specialized knowledge for the patients that need it the most, especially with and I think we'll talk about this a little bit later but with the shortage coming. How do we use those people the most effectively and how do we use other aspects of health care? 

The other barrier that sometimes happens is related to implementation and so logistics. So you mentioned to the injectable version of PrEP, there's a lot of logistical barriers related to that. And how do we overcome the education around that as well as there's some concern across testing and legal liability. 

Dr. Allison:

Yeah. What you say about utilizing primary care providers in HIV care, you said it's your opinion, but I think there's a lot of consensus around that. The HIV Medical Association for a long time now has had a statement, out to that non-specialist providers supporting non-specialist providers with adequate training to manage HIV care. And across the board, not just, for infectious disease and HIV. We're seeing a lot of this good idea of integration of care into primary care. You know, you see integration of behavioral health, you see integration of Hepatitis C treatment. You see integration of HIV care into primary care. So your points are very important and valid. 

[06:37] What solutions have you implemented or are aware of? 

Dr. Allison:

What solutions have you implemented or aware of in that context? You know, in terms of HIV care. 

Dr. Hodge:

So my favorite right now is going at it from the education perspective, which is kind of the theme for today. So really trying to increase HIV prevention and awareness by changing what is baseline expectation competency for all health care professionals. And one of my favorite projects is one that I'm working on with you.

It's called TAKE on HIV, and it's a HRSA sponsored grant that has the goal of supporting health professions programs to integrate the National HIV Curriculum by the University of Washington into our health professions in curriculum or curricula, and I personally use it, so I think that this is a great tool to try to help increase the education and baseline competency.

[07:18] National HIV Curriculum (NHC)

Dr. Allison:

So for those listening who are not aware of what the National HIV Curriculum is, could you talk a little bit about that and describe that? 

Dr. Hodge:

Yeah. So this is a wonderful tool. I actually really like it. It's a free online curriculum. You do have to sign up for an account just to create a username and password, but it's free, right. And it's got this really robust curriculum with six different modules. And it's continuously updated.

And it's great for both clinicians as well as just health professionals in general that are looking to learn more about HIV. The different modules include screening and diagnosis, basic HIV primary care, antiretroviral therapy, which is where I do a lot of things. I incorporate it into my courses as well as co-occurring conditions, prevention of HIV, and then key populations.

They've got not just the modules for learning, but they've got drug reviews. They've got some great animated videos related to that. They've got a question bank. They've even got a podcast and mini lectures. They've got symptom guide. So not just can I integrate the curriculum from like a learning standpoint, but with the different resources to continuously stay up-to-date, I think is also a wonderful tool.

[08:20] Could you expand a bit on how you yourself have used the NHC?

Dr. Allison:

Could you expand a little bit on how you yourself have used the NHC, the National HIV Curriculum? 

Dr. Hodge:

Yeah, so I actually have the antiretrovirals module almost completely integrated into my courses. I teach a couple of courses in our College of Pharmacy curriculum where I teach HIV. I've got several lessons almost entirely on antiretrovirals, a couple on the co-morbidity conditions, and then I've got a few lessons in a couple of other courses that I'm not the director for. So I've tried to reach out to my colleagues to have that sustainability model so that, you know, should something happen and maybe I can't get to everything in this one. At least the students are exposed to it, multiple other courses. And then one of the cool things is that our program and our College of Pharmacy, we have a co-curricular curriculum.

So it's trying to have those holistic, well-rounded pharmacists. And within that there's actually a specific domain related to inclusion. And so we've got several of the key populations module from the National HIV Curriculum worth credit towards that curriculum. So it's even not just directly in our course, but it's an opportunity to receive credit for other curricular needs. 

Dr. Allison:

Excellent.

[09:24] Adaptations

Dr. Allison:

So how do you think the HIV workforce will need to adapt going forward into the future to providing adequate care for people with HIV? 

Dr. Hodge:

Yeah, I think this is a wonderful question that we're all kind of struggling with. And I've kind of alluded to this idea of leaning into multi-disciplinary care. You talked about an integrated model, which I think is wonderful and truly triaging who needs that specialist level of attention. About 65% of our people with HIV are virologically suppressed. So if you're already virologic suppressed and you say virologically suppressed for a certain amount of time, do you really need an HIV specialist as your primary care provider or can you maybe see a primary care provider, a general primary care provider who can be a better spent. I shouldn't say better, but I mean they are the experts in multimorbidity conditions, right? Um who can handle all the other non-HIV conditions probably a little bit better because your HIV is well controlled. So how do we lean into that? Like say cardiovascular disease is something that we're starting to see. We know that patients with HIV are at risk for obesity management, something we're starting to see an increasing amount in our people with HIV, which we used to think of as unheard of. But now it's actually becoming pretty common. Diabetes and all those things. 

HIV specialists aren't the only ones that are actually experiencing a shortage. Primary care is also experiencing a shortage. So I think we have to be careful about not just saying, like, hey, our primary care colleagues can do that, but also thinking about that multidisciplinary piece, right? So can we have a primary care clinic that has an ambulatory care pharmacist that's involved? Who can handle some of the comorbidities and be like a diabetes expert, for example. Can primary care help with some of the screening? Like, say, pap smears for cervical cancer or anal cancer screenings? Right. Not just the multidisciplinary forum. And obviously I'm going to promote pharmacy as a pharmacist of it from that standpoint. But other force multiplier. So how do we get out into the community? So thinking about community pharmacy for also. Right. And one thing I want to highlight here is it really depends on your state. But there are some states that allow pharmacists and different nurse practitioners and PAs is to have PrEP clinics, which I think would be huge and we don't, as far as I'm aware, don't currently have that here in Texas. But I know a couple of other states where that is a thing. And I think that that's a huge force multiplier to try to increase access to PrEP, that pre-exposure prophylaxis, to try to decrease the number of HIV cases so that we can really try to get a hone in or try to decrease the, the proportion of people impacted by HIV, and I think that those are a couple of steps that it would be relatively, quote unquote, air quotes, to implement. 

Dr. Allison:

Yeah. It's it's all hands on deck, isn't it. It's, it's it's going to take all of us to end the HIV epidemic across multiple disciplines. You know, across multiple types of expertise, really coming together to, to make that happen.

[12:12] What concerns you the most about the future of HIV care?

Dr. Allison:

What concerns you the most about the future of HIV care Dr. Hodge? 

Dr. Hodge: 

We are so close. Like HIV has come such a long way to ending this epidemic, and I'm really most concerned about policy changes that would prevent us from achieving that, I think ending the HIV epidemic is possible in my lifetime. We mean, God willing, I have several years left, so I think it's possible if we keep pushing and we really have to keep pushing.

And actually and we've learned this from a couple of other diseases like, say, smallpox towards the end, where it seems like the, the goals you set, you have to push even harder. But I think that eradication is truly possible. And so I really think that my biggest concern is related to advocacy and policy. 

Dr. Allison:

What are your thoughts around the fact that because our drugs are so good, and because people living with HIV are so well, do you think that HIV has fallen away from public consciousness as an issue?

Dr. Hodge; 

That's an interesting question. You know, in the U.S., maybe a little bit. Globally, not as much. I think that globally we still have quite a few cases and that access to drugs, to the really good drugs can be limited. And so I think it's like, say in Africa where some of the highest case counts are case counts are, some of those countries don't have access to some of our best drugs.

And so I think that it's still a pretty prevalent problem there and is still on the global mind in the U.S. Mind you, I think you bring up a great point. Like it may slowly start to fade from the urgency need.

[13:37] What aspects of the future of HIV care are you most excited about?  

Dr. Allison:

What aspects of the future of HIV care are you most excited about? 

Dr. Hodge:

I love this question because when I teach HIV, when I talk about the history of HIV, that's when I really get the most animated and the most excited because we've come so far, right?

We went from a death sentence within 5 to 10 years to it's now a chronic condition, which is just huge. Like, talk about a game changer with medicine, right? It's not quite the same level of Hepatitis C where now we have a cure, but we're so close, we're on the precipice. So I really, really get excited when I'm talking about the advancements in HIV and how we have patients that are living almost the same life expectancy as the general population, which I think is huge.

The fact that we have patients with so much multimorbidity that's not related to our drugs, it's just related to living longer. And we have older adults that have HIV. I think that's so cool. I mean, it's not so cool for them, but the fact that it exists is cool, right? And so that's what I get most excited about, is thinking about the trajectory and how close we are to a hopefully a cure.

Dr. Allison:

Yeah. And I like to use the term functional cure. We don't have a cure for HIV, but we we kind of have a functional cure, right? Just like you say, those that take their medications and they're undetectable, able to have almost exactly the same life expectancies as those without HIV. And that that is huge. 

[14:57] What advice would you give to someone considering a career in Texas-involved HIV care?

Dr. Allison:

What advice would you give to someone considering a career that involves HIV care?

Dr. Hodge:

So I think this is a bit of a multi-component answer, but one of the biggest things I would say is to make sure that you're seeing an advocate for your patients. And maybe this doesn't just apply to HIV, it applies to ID in general. I think that it it's definitely applicable to HIV as well, where we want to do what's best for our patients. But we often feel like we have to compromise, um because of either access or logistics or whatnot. So maybe we get used to the compromise and we really shouldn't be used to the compromise. We really need to be pushing for that gold standard therapy. And then if we have to use a bronze standard therapy to still achieve our goals, as long as we're achieving our goals, that's great. But try to always shoot for the gold, right? So making sure that you're always being a patient advocate. 

The other thing for someone who's going into HIV care, I think in particular, is learning a little bit more about the health care system, because we live very much with a broken system. And so how do you optimize care delivery within that system? Right. Like if you know the rules of engagement, then you can play the game a little bit better. I think that that's a huge piece as well as the advocacy. And then as I mentioned earlier, that multidisciplinary and integrated care model. 

[16:05] Conclusion

Dr. Allison:

So thank you, Crystal. Thanks, Dr. Hodge, for sharing your journey with us.  And that brings us to the end of today's episode. I want to again, thank you, our listeners, for joining us today. If you liked what you heard, don't forget to subscribe to the Red Ribbon Report so you never miss an episode. 

Join us again on the Red Ribbon Report, where we bring real people with real stories and real perspectives from the HIV workforce. Until next time we look forward to sharing more HIV workforce conversations.

Dr. Hodge:

Thanks for having me. 

[16:39] Credits

The production of the Red Ribbon Report podcast is supported by the Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services (HHS) under grant number HRSA-22-022 and AIDS Education and Training Centers Program (TAKE on HIV). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the United States Government.