Better medications and new strategies help make it possible to achieve our goal of ending the HIV epidemic in Texas.  For a person with HIV, antiretroviral therapy (ART) dramatically reduces HIV-related morbidity and mortality. Immediate linkage to care and treatment is essential for someone diagnosed with HIV. Sometimes called “rapid start” or “test and treat,” rapid initiation is a process that connects newly diagnosed people to treatment and medication within a very short time period, ideally one day.

Achieving Together interviewed Dr. Ogechika Alozie, Medical Director of Sunset ID Care in El Paso, Texas, about his experience implementing rapid initiation.

Please tell us about the use of rapid initiation at Sunset ID Care. When and how did it begin?

For us, the conversation around rapid start was something we began entertaining around 2016 or 2017. This was around the time when UCSF made their initial data presentation about their work with rapid initiation. We began to realize that the faster we got someone onto medication, the better. We also had a host of medications that could be given early without any higher risk of resistance. In 2018, we at Sunset ID Care started really thinking about it and got some money from the state and the feds to create our HIV Navigator position. I often talk about PPT: People, Process, Technology. This is what made implementing rapid start possible. We had the person, the Navigator. This role was really important in terms of creating a liaison between the testing location and getting people into care. We worked out the process, which was how we were going to operationalize things. We also had a range of technology available, including an EMR and text message service. So, we decided to try it out. At first, we thought: Should it be a week? Or 72 hours? Then we decided, no, let’s go for (starting medication) the same day.  So that’s how we designed the program. The more we tried it, the more our partners, including the health department and county hospital, started seeing the efficiency of being able to diagnose somebody and get them on a pill the same day.

What challenges have you faced in doing this? How have you addressed them?

Initially, the biggest challenge was getting people to believe we could do it. It took a long time to get funding for the Navigator position and other things we wanted to do. The next step was operationalizing it and working out the process. I often tell people that everything doesn’t have to be perfect on day one, but you have to have a direction and you have to have a goal. As you’re going along, every two weeks or month, look at what’s working and what’s not working and tweak things. We would continually adjust until the process was smooth. With our processes in place, fast-forward to COVID times, and we were able to transition quickly to telemedicine.

Establishing relationships was critical to our success. We don’t do testing internally.  We’ve never been set up like that – we deliberately set ourselves up as the referral site. We focused on what we thought we could do really well. We wanted to make sure that our partners, especially the health department, understood that we were the go-to for HIV treatment.

Sunset ID Care is a standalone clinic but we partner with Project CHAMPS and we’re all in the same building, so we have the case management side and clinical side co-located. It’s helped us create a really good cohesiveness and work flow to allow us to provide the best possible care for patients. 

In terms of patient linkage to care, what have you seen since starting rapid initiation?

The biggest thing is the reality that if you give patients the option and opportunity to engage with healthcare quickly, they will do it. We’ve had this misconception in the past that people need time to be mentally ready for care. And there may be people who are like that. But what we’ve seen time and time again is that people want their care. If you give them a system that works, they will come into that system.

Once upon a time, we in HIV wanted the clinical staff or the case management staff to do the role of the HIV Navigator.  It’s possible to take case managers and have them adapt to that role, but anyone who has do that as their part-time job isn’t going to do it as well, because the value of an HIV navigator isn’t just navigating the patient into the system, but it’s creating relationships with outside partners. Historically, we in HIV have failed at partnering with each other. We think one organization wants to eat the whole funding pot. If you focus on what you do well, you can partner with people who do other things on the spectrum. Our organization has specifically and deliberately decided not to grow outside of what we do really well. We bring in partners to extend the services our patients receive. I think that attitude, of wanting to build partnerships and bridges has helped us.

It’s hard to say what the direct contribution of rapid start is to our community viral load. I understand from our data that our community of El Paso, as a whole, is doing well in terms of the spectrum of care and viral suppression. I don’t think it’s a simple cause and effect – I believe in bundles of care. One intervention isn’t the sole intervention that causes anything to change, but when you stack interventions on top of each other, you get a bundle effect that provides improved care, improved cohesion, and hopefully improved patient satisfaction.

What tips or recommendations do you have for other organizations who are interested in implementing rapid start?

It’s a journey. Each organization comes from a different stage in that journey. If you’re starting from scratch, the biggest thing that people need to understand is that inertia paralysis is the biggest problem. People get so freaked out by the process that they never do anything. They put a committee together, they give one or two people a task, and two years later they still haven’t done anything. I tell people all the time that you have to try. You can’t score unless you shoot. Be willing to fail fast. That’s the key. Failure is not the problem. But, if you’ve failed for three years, you’ve stunted the growth of your organization. Be able to fail over 90 days and then pivot. Be willing to look at what happened, what went wrong, and how can it be fixed.

For my physician colleagues, I’d say: Stop trying to be the quarterback. This is more like soccer. We’re all on the playing field, we all have a role. When we start thinking we’re the boss, we become less willing to delegate tasks. You have to allow the clinical pharmacist, the nurse practitioner, the RNs to take on some of the challenges and some of the clinical pieces. 

What resources/information do you suggest would be useful for an organization just starting out with implementing rapid start?

Texas DSHS is a great resource. AETCs across the state also provide a wealth of knowledge. They’re able to bring together people from across the state and outside the state as well.

Thank you, Dr. Alozie, for sharing your insights with us! Be sure to check out our previous interview with Abounding Prosperity about their use of rapid initiation.

Dr. Alozie is an infectious disease specialist serving patients in El Paso, Texas. Dr. Alozie is board-certified in infectious disease by the American Board of Internal Medicine (ABIM). He is also board-certified in clinical informatics by the American Board of Preventive Medicine (ABPM), making him one of less than 100 such certified physicians in the state of Texas.

He is a Fellow of the American College of Physicians (ACP). Since 1975, over 35,000 physicians have earned ACP Fellowship, a mark of distinction representing the pinnacle of integrity, professionalism, and scholarship for those who aspire to pursue careers in Internal Medicine

Dr. Alozie received his medical degree from the University of Benin – Faculty of Medicine in Benin, Nigeria. He completed his residency and internship in internal medicine at Hennepin County Medical Center, followed by his fellowship training in infectious disease at the University of Minnesota.

He was recognized as the 2016 “Best Physician in the City” by City Magazine, El Paso. He was also awarded the “Pharmacy Award for Innovative Practice” by the El Paso Pharmacy Association in February of 2018. As an infectious disease specialist Dr. Alozie believes patient care is the most important part of medical care.

Learn more about Dr. Alozie and read a press release from Health News Today.

Reflections on the Achieving Together Long-Term Survivors Webinar

On June 5, 2020, in celebration of Long-Term HIV Survivors Day, Texas HIV Syndicate member Barry Waller led a panel discussion with three long-term survivors here in Texas. Participants came from across the state and had a combined experience of 88 years of living with HIV: Gary Cooper, Austin; Glenda Small, San Antonio; and Steven Vargas, Houston.

When I tested positive for 1985, there were no services or treatments for HIV – only fear, government indifference, and the threat of being rounded up and quarantined. Friends were dying all around me, friends far more accomplished in life than I had been.

-Gary Cooper

Long-Term HIV Survivors Day, started by Tez Anderson of Let’s Kick ASS (AIDS Survivor Syndrome), in 2014 recognizes the resilience and strength of long-term survivors of HIV. Tez chose June 5 because it is the anniversary of the first reporting of cases by the CDC of what would later be known as AIDS.

Long-term HIV survivors are defined as those who have been living with HIV for more than 20 years. Currently, there are almost 19,500 Texans who have been living with HIV for more than 20 years.  These long-term survivors represent two out of every ten Texans living with HIV.

Hopefully we can get together and do this thing right and become as one and realize that everyone is a human being, and everybody deserves to live, and everybody deserves to have a chance.

-Glenda Small

We want to celebrate the long-term survivors currently living in Texas.  Long-term HIV survivors bring so many strengths with them to the fight to end HIV.  Many also face a number of unique challenges, including medical care, medication, housing, social isolation, and more. 

I had to do my part. I had to step up and use what I learned to help other people. And so I did.

-Steven Vargas

You can watch the webinar here and listen as these three individuals share their unique stories, perspectives, and wisdom:  

Embracing Telemedicine: One Doctor’s Experience

For Dr. Gene Voskuhl, Medical Director at Resource Center’s LGBTQ Health facility in Dallas, Texas, telemedicine started as a means to help rural patients with the added benefit of shortening his own exhausting commute. He now believes that telemedicine serves a broader purpose. When asked how telemedicine is linked to ending the HIV epidemic in Texas, he responded, “Without a doubt, I am convinced that telemedicine is an option for people who have barriers to medical care. Sometimes it is as simple as transportation, time, sometimes it’s kids or family. I am convinced this will increase retention to care and the number of people in treatment.”

Dr. Voskuhl began exploring telemedicine in 2018 when he was working with the Callie Clinic in Sherman, Texas. He lived in Dallas and commuted to Sherman three days a week while also working part time with the Resource Center as they worked to open a new primary care medical program. He loved the people and the patients at the Callie Clinic and wanted to find a way to continue to work with them even after the new Resource Center LGBTQ Health facility was up and running.

In 2019, Dr. Voskuhl attended a two-day training at Texas Tech that provided IT training for telemedicine. That summer, he created a home-built system, which he now refers to as a bit of a “Frankenstein system,” while the CFO/IT staff at the Callie Clinic pulled the in-house telemedicine equipment together. They used a Zoom platform which had patient health information (PHI) encrypted. Patients at the Callie Clinic would go to the clinic and Dr. Voskuhl was able to see them online from his home. That was the beginning! When the Center’s LGBTQ Health opened, Dr. Voskuhl was able and willing to continue to serve his patients at the Callie Clinic using the telemedicine platform.

Once the coronavirus arrived, things began to change. With more barriers in place for patients to physically attend clinic appointments, it became an easy decision to add telemedicine at Resource Center. They had already been exploring the use of telemedicine for PrEP, so this just put the plan into high gear. Additionally, the Texas Medical Board (TMB) temporarily relaxed some of their previous telemedicine restrictions. Providers are now allowed to conduct video or phone appointments whereas in the past appointments had to be live video (synchronous) calls. Dr. Voskuhl is able to connect to patients at the Callie Clinic through the clinic’s EMR system. Instead of dialing in to the Zoom platform, he can dial into the Callie Clinic directly on his phone and patients have the option of telemedicine via video or telephone. At LGBTQ Health, he starts with a telemedicine visit to do an initial screening and can then have patients come in if he needs to see them in person. When asked if he hopes the TMB will continue to allow phone appointments he said, “Absolutely! Partly because Texas is so big and diverse that coronavirus hot spots will continue to pop up – so allowing me or other physicians to deal with those locally makes the most sense. There is no other way to think about this other than that the flexibility allowed has saved lives.”

Dr. Voskuhl has learned a few lessons, both about himself and about telemedicine.

  • Personally, he still requires some face-to-face time with clients and co-workers.
  • He has found that it is good for him to be on a schedule while working from home and it is important to go out at times.
  • Listening is the most helpful aspect of his telemedicine calls.
  • Asking people about their experience with telemedicine and what he can do differently is important. Some people love the telemedicine option and some absolutely hate it – they just don’t feel connected. He believes you can’t force telemedicine on people: “You can support it, but you have to be flexible.”

Dr. Voskuhl goes to the Callie Clinic once a month to see patients who prefer in-person visits, although he is not traveling right now due to the coronavirus.

From a technical perspective, lighting and especially audio are very important. You have to project a little bit more on the camera and be more animated on screen. There are a lot of little lessons to be learned – “like you have to move the mouse around every now and then or the screen goes dark!”

Dr. Voskuhl’s advice for others is, “Don’t be afraid – it seems daunting, but it is really not.” He said, “Hey, we did it, anybody can do it. There are online resources out there, online (TexLatrc.org for example), in-person and on the telephone. Don’t be afraid, because if you don’t know the answers there are people with the answers who can help you figure it out.”

Initially, he believed telemedicine was a way to link rural patients to care. Now, he sees that urban folks have many of the same barriers to accessing medical care. Telemedicine is a good way for many different patients to connect to medical care. When asked if he recommends telemedicine for others, Dr. Voskuhl said, “Absolutely, this is a tool for Texans, for our HIV folks and PrEP, to connect with medical care. One, it is important and two, it’s not that hard!”

Dr. Gene Voskuhl graduated from the University of Oklahoma, where he specialized in infectious diseases and eventually helped launch the University’s HIV Clinic. He later worked at Gilead (the manufacturer of PrEP medication Truvada) as a medical scientist, instructing fellow physicians on how to safely treat LGBTQ patients and prescribe appropriate pharmaceuticals. Volunteering for Resource Center gave him an even deeper insight into the needs of the LGBTQ and HIV populations in North Texas, and further fanned the flames of his passion towards equity in healthcare. He is currently the Medical Director at the Center’s LGBTQ Health facility, which provides affirming and compassionate care in a stigma-free environment.

Whatsinthemirror? Addressing Mental Health Among the Queer Community of Color in Central Texas Through the Arts

Tarik Daniels, the 2019 winner of the Austin Under 40 Award for Arts and Entertainment, sat down to chat with us about his work here in Austin, his journey to becoming a playwright, his passion for tackling mental health in the Black queer community, and his current projects with the organization he founded and for which he serves as executive director – whatsinthemirror.

Shortly after moving to Austin in 2012, Tarik procured his first grant from the city that allowed him to focus on playwriting. While working with the Austin Creative Alliance, he started whatsinthemirror as an initiative of their work, but branched out in 2016 to develop the project as its own independent organization focused on using art to address the intersections of mental health in the black queer community, particularly around HIV. Since 2016, whatsinthemirror has produced a play each year, starting with “The Counseling Session,” Tarik’s first play script based on an experience with suicide he witnessed as a 15-year old in Detroit. Tarik felt a natural fit with writing about the intersections of mental health and HIV in the black queer community, as he found that many folks in his community “weren’t able to find outlets in the mental wellness spectrum that allowed them to be free, to be true about what was going on in their life” and were contracting and dying from HIV at higher rates than their counterparts. He wanted to use art and his story to help others get rid of the shame and the stigma around mental health and HIV. He also says that he’s “always been around people with mental illness; that was normal to me. It was always a battle in our family,” and therefore the combining of passions is such a natural fit for him as he pursues this work. 

The U.S. Department of Health and Human Services Office of Minority Health reports that Black communities are more likely to report serious psychological distress.  The National Council for Behavioral Health found that Black Americans are less likely to seek out treatment and more likely to end treatment early.  The intersections of Black and queer identities only increase daily stresses of entrenched racism and homophobia, increasing the likelihood of psychological distress.  However, there are very few opportunities for accessing competent and affirming treatment. Less than 2 percent of the American Psychological Associate members are Black and many people who do seek out help, report experiencing racism and microaggression from their therapists.

Whatsinthemirror is a healing justice social movement that provides suicide prevention and mental health awareness to communities of color through art, advocacy, and affirming care with a focus on LGBTQIA+ people, youth, and women. The organization currently has two main projects: the development, publication, and promotion of a mental health database for the queer community of color in Central Texas, and their latest project, ArtHeals, started in January 2020 thanks to a grant from COMPASS/Gilead.

The mental health database came out of a realization through their work in the community hosting events connecting mental health/wellness practitioners with community members, and recognizing the need for a one-stop resource for queer people of color in Central Texas to find affirming practitioners. All database listings have been called and vetted by the organization and can be found directly from their website: https://whatsinthemirror.org. While the database currently functions as a Google spreadsheet, their eventual goal is to create a standalone website and app.

Their biggest current project is the ArtHeals project, which was recently awarded a Transformative Grant from the University of Houston Graduate College of Social Work as part of the COMPASS Initiative® to build on community-driven solutions that are reducing stigma and improving the health and wellbeing of those impacted by HIV in the South. With this grant, whatsinthemirror is currently running several support groups (currently meeting virtually) for Black queer people living with HIV and allies. This work also includes a Mental Health Monday Facebook live event. Through the support groups, they feature guest speakers each meeting and spend time planning their culminating event the Art Heals Festival, a multimedia social justice festival, occurring in August of this year. The festival, which will occur primarily, if not entirely online, at this point, strives to end HIV stigma through art, particularly among queer people of color, and will provide a platform for empowering people living with HIV to both showcase their art, but also take part in the planning process.

The festival aims to create a forum for dialogue and collaboration between diverse communities united by an interest in local social justice issues and to support the community of progressive artists, activists and community workers. They are currently looking for provocative, radical, inspiring, empowering, innovative and/or enlightening works from across the artistic media (i.e., film, poetry, performing arts, music, visual arts and anything else you consider art). Proposals must address local social justice/activist/human rights issues. To learn more about the festival, the mental health database, whatsinthemirror, or to submit a proposal, visit whatsinthemirror.org.

Finally, we asked Tarik his recommendations for organizations looking to address mental health among people of color living with HIV in their own work, and you can listen to his response here:  

Tarik Daniels is an AfroQueer artist and HIV & mental health awareness activist. He is the Founder and Executive Director of Whatsinthemirror?, a social movement that provides mental health awareness and suicide prevention through art and advocacy to communities of color. Currently serving as a City Commissioner for Austin’s LGBTQ Quality of Life Advisory Board and HIV Planning Council. Tarik has written, directed, and produced several plays and released a novel, No Bonds So Strong, in 2018 and cohosts the Black queer podcast, What Works for Us. He is the winner of the 2019 Austin Under 40 Awards in Arts & Entertainment, 2019 Richard “Torch” Hopkins Community Leader from Integral Care, and 2020 SXSW Community Service Honoree Award. 

“P.S. I Love You,” a Black Man’s Quest for Love

By Jeaux Nathan Anderson, Jr

Austin Mahogany Project play explores the idea of love between Black Men

The Mahogany Project is a collective of Black queer individuals who use prose/poetry/storytelling and theatre to highlight our experiences and heal our pain.

The Mahogany Project was born after my friend William Lyons attended a conference teaching people how to use art as a vehicle for activism. Since he knew I was a writer, we partnered to create this group. We used our spades nights, formally called “sweet tea discussions” about once a month to come together and would chat about a topic then folks would hang out, drink, eat, and play spades. The shade was incredibly real during these times and it was dope to meet new people as well! We used these gatherings as an opportunity to talk to Black queer men in social settings and get content to use for our shows. The project was born out of exhaustion from other people telling our narratives without our permission. The Mahogany Project has been performing every summer (except 2019) with new volumes of work with each corresponding summer. Our troupe (currently six members, but has consisted of upwards of 15 in the past) writes all of our work and this is pretty much what started me in theatre as a performer and a writer. Performing work written by people who don’t identify as Black and queer isn’t something I am interested in at this time. I want to ensure the voices of our community and our work are being amplified.

P.S. I Love You (PSILY) was the third installment in what we call The Love Jones Series which explores the idea of love between Black men who love Black men. It follows the first installment, Love Jones (2017), and the second installment, For Lover’s Only (2018). PSILY is the conclusion to the series of a Black man’ s quest for love. The love of a partner. The love from community. And ultimately the love of self. I feel PSILY is one of the most authentic pieces I have written before. I drew from my own insecurities to write this show: the hurt and the pain I feel is apparent, but also the joy. 

PSILY is the merging of live music, singing, and poetry to tell a love story. (Think Jill Scott mixed with Tiny Desk Concert and Def Poetry Jam.) The plot for this show is simple: it’s a love story that explores the intersections of race, sexual orientation, and body issues. I use art to heal from pain and scars that I’ve experienced and this show is really no different. As a thicker and bigger Black gay man, the world sometimes strips us of our sexiness and vibrancy. I wanted to use this show to tell the story of someone who sees his insecurities as strengths. This show is to address the feeling of being Black in White queer spaces, being queer in Black spaces and how that impacts being in love with a Black man as a Black man. 

I think our shows are different because they don’t have specific character names usually. The benefit is that people can imagine who that character is for them personally. For our Love Jones Series, I perform as if the story is mine – because it is. I wrote three love stories, each based on the idea that we all get three loves in our lifetime. (I read this somewhere and thought it was cute.) I wrote about my first love who taught me how to be intimate and vulnerable. I wrote about my second love who taught me how to have an adult relationship. I wrote about my last love who taught me to love me. PSILY and the corresponding shows were written to follow this pattern: The hurting, the healing, the hope. PSILY is here to give people hope. We all want someone to win and find the person they are destined to be with. I want to use this show to fulfill the audience who have been on this journey with me for three years. Our next show will have the title Legacy and will highlight not only the legacy of our ancestors, but the legacy we’ll be leaving behind and the fight that will continue.

Since I work in HIV prevention, I think it’s incredibly important to partner with organizations during our shows. Over the past years we’ve partnered with various sexual health organizations to be at our events and to promote their HIV/STI testing programs. Austin Public Health, Kind Clinic, and ASHwell have all sponsored a show and brought their services to the people. Our shows sometimes involve sexual topics and we want to highlight that sex should be fun and pleasurable for both partners. No matter what type of sex you’re having we want you to enjoy it. But we also want to let people know they have options to experiment with ways to reduce risk of HIV/STI transmission. We also want to normalize getting tested with our partners. That conversation has to be had. 

Upon reflection after the show, it was fantastic. Truly amazing. Spectacular. There were tears, laughs, and love. I think the best way to describe the night is we felt triggered and the words/music helped us heal. We moved past hurt and made magic and memories that night. There are no words to describe the night other than for an hour and a half we were all able to reflect on love and feel hopeful. It was dope. We were all able to realize that even in darkness there is light. And the light is in our legacy and lineage as black queer folks!

The ultimate message I wanted people to walk away with is that we can be our own daddy. We can be our own prince charming or princess. We have enough within ourselves to be what we want and to love. We are dope. PERIOD. We define what love looks and feels like for us. I encouraged everyone who came to the show to know that this is a safe space to own that idea. 

Jeaux Nathan Anderson, Jr is a playwright and activist living in Austin, Texas, hailing from Dallas originally. He wrote, produced, and acted in his most recent production, P.S. I Love You, performed by the Mahogany Project at Cheer Up Charlies in February in Austin.  

My name is Jeaux Nathan Anderson Jr and I am proud to say I was born in the “Big D”—Dallas, Texas. I’d say from a young age I was always interested in storytelling. I remember using my toys to create fictional worlds and create characters that were reminiscent of the daytime soap operas my grandmother used to watch. My grandmother didn’t realize it at the time, but during these formative years she was crucial in my development as a storyteller. I became fascinated with the stories of our family that she’d share with me. It was in the 7th grade that I wrote my first piece and, please know, it was awful. The title was Double Dutch Chocolate, which is ironic because I actually don’t even like chocolate. But from there, the seed was planted and I continued to work on my craft through high school and the beginning years of college. During my time as a student at The University of Texas at Austin (UT-Austin) I started to share my work and actually perform. I grew more comfortable with my voice. I came out. I started to grow into the person I am today. Most importantly, I met William Lyons. Will was my first access into what it meant to be a Black gay man and introduced me to many of the friends I still have today. He and I grew from co-workers to “bristers” (brother sisters) during our time as orientation advisers at UT-Austin, and it was with him that I worked to create what is now The Mahogany Project in Austin.