For years, while a student at the University of Miami Miller School of Medicine, Hansel Tookes fought the Florida legislature to pass the first law in the state that would allow drug users to exchange used needles for clean ones in an effort to combat HIV transmission among at-risk groups.
On Thursday, after four years of fighting and on a day that coincides with World AIDS Day, the pilot needle exchange program begins in Miami-Dade.
“Syringe exchange is one of the most evidence-based interventions we have to prevent HIV,” said Tookes, M.D., M.P.H. “As the heroin epidemic in South Florida flourishes, we now have the proper tools to keep this population healthy. Harm reduction works and now Miami will join other progressive U.S. cities to better service our citizens.”
The pilot program, the IDEA Exchange named after the Infectious Disease Elimination Act, is just one area where University of Miami health officials have been working to find a cure and stop the spread of HIV/AIDS.
“The HIV statistics in Miami are sobering and now it’s become a personal mission to stay working on HIV until it’s vanquished,” said Mario Stevenson, Ph.D., the Miller School of Medicine’s chief of infectious diseases and Director of the AIDS Institute.
As Stevenson notes, the HIV epidemic in Miami-Dade – which has the nation’s highest rate of incidence – extends beyond basic science.
“Much of the challenge is really dealing with societal issues in terms of how HIV thrives on substance abuse and lifestyles,” he said. “Those are the effects that we have to deal with to fight this epidemic.”
Miami has been a battleground for the HIV and AIDS epidemic since the early 1980s when the then-mysterious, immune-attacking virus first surfaced. The emergence of HIV and AIDS quickly propelled University of Miami physicians to the front lines of one of the deadliest and complex epidemics in modern times.
Seeing a swell of symptomatic women and dying infants, doctors at the School of Medicine were among the first to sound the alarm about the disease. Miami’s close proximity to endemic countries in Latin America and the Caribbean, rising substance abuse, homelessness and mental health are just some of the unique factors that have made Miami-Dade County the HIV epicenter, having both the highest rate and incidence of HIV and the largest and most diverse infected population. Broward County also consistently ranks among the nation’s top HIV-plagued counties.
Over the past three and a half decades, University of Miami Health System infectious disease physicians along with public health experts, psychologists and a team of world-renowned scientists have implemented a unique comprehensive care model and devised tailored population outreach strategies that range from rapid testing, strong community alliances and aggressive adolescent outreach, among other innovative initiatives. The pioneering work of UM pediatricians has nearly erased mother-to-child transmission in Miami. UM’s wide-ranging research has led to groundbreaking HIV drug discoveries and has served to inform top U.S. research institutes on what approaches are effective, especially among minority women. Across the University, scientists in high-tech infectious disease labs busily work toward a cure, vaccine and new therapies.
Stevenson, a renowned scientist, is one of three top infectious disease scientists who relocated their labs to Miami in recent years for greater access to Miami’s diverse patient population. UM’s HIV research arm has allowed thousands of patients to be enrolled in clinical trials that give them access to new therapies and help improve their overall health.
Stopping the Spread
Adding to its arsenal of outreach strategies is UM’s pilot needle exchange program, along with ramped up efforts to reach at-risk communities with the highly-critical pre-exposure prophylaxis (PrEP) drug that blocks the transmission so effectively that it has been likened to a vaccine. These measures may represent a turning point for Miami, as they were key to reducing HIV in other U.S. cities such as San Francisco.
The University of Miami Health System is collaborating with the Miami-Dade County Health Department to start a PrEP clinic that will allow enhanced access to PrEP for Miami-Dade County residents. “New strategies such as PrEP have revolutionized the way we think about HIV prevention,” said Susanne Doblecki-Lewis, M.D., associate professor of clinical medicine, and a PrEP expert leading the effort. “Our work now is to make these very effective interventions available to everyone in Miami who could benefit from them.”
In another innovative research project involving PrEP, renowned UM infectious disease physician Margaret Fischl, M.D., professor of medicine, Director of the Miami AIDS Clinical Research Unit and Co-Director of the Miami Center for AIDS Research, will be targeting transgender women with longer term inter-muscular injections of the drug. Transgender women, she said, tend to have higher rates of drug use and risky sexual behaviors.
“As part of our work, we continue to identify vulnerable populations and employ different modalities to prevent transmission, improve adherence and in turn stop the disease from replicating in those who are infected,” said Fischl, whose early pioneering research was instrumental in gaining FDA approval of AZT, the world’s first antiretroviral drug treatment for AIDS that would later be widely used to prevent transmission of HIV. “Longer term injections of PREP will greatly boost adherence, which has been one of the greatest obstacles in stemming HIV.”
Needle exchange is another new promising initiative. Florida was one of just 15 states that lacked a needle exchange program despite Miami-Dade having the highest rate of HIV and skyrocketing heroin use. Hansel Tookes, M.D., M.P.H., a Miller School-trained resident with a background in public health fought four years for passage of the state needle exchange bill, which was passed in April 2016 and authorized the Miller School of Medicine to conduct a five-year exchange program on a pilot basis within Miami-Dade County.
In addition to receiving clean needles, participants will be educated on safe injection techniques and offered immunizations, as well as viral hepatitis and HIV testing. The program will also link drug users into treatment programs and link those who test positive for HIV or hepatitis to health care – with the goal of reducing the spread of these diseases.
“Syringe exchange is one of the most evidence-based interventions we have to prevent HIV,” said Tookes. “As the heroin epidemic in South Florida flourishes, we now have the proper tools to keep this population healthy. Harm reduction works and now Miami will join other progressive U.S. cities to better service our citizens.”
Changing Behavior, Changing Outcomes
Given the psychological burdens and barriers associated with HIV, behavioral health has long been a crucial component to UM’s role in connecting people to care and stemming transmission. Since the 1990s, psychologists and behavioral health specialists in the Department of Psychology on UM’s main Coral Gables campus and the Department of Psychiatry and Behavioral Health Sciences on the Miller School campus have rigorously studied risky sexual behaviors, mental health patterns and barriers that contribute to HIV. Addressing the epidemic from a behavioral and mental health perspective allowed UM psychologists to create effective interventions and group therapy sessions that have helped HIV-infected minority women overcome the stigma and obstacles to care. The behavioral research also found that most infected women continue to be sexually active (often times unprotected) and go on to have children, which prompted UM behavioral health experts to collaborate with physicians to devise and implement interventions that provide pre-conception counseling. The project educates young HIV-positive women and teens on safe sex practices, including adherence and the role of PREP, preventing mother-to-child-transmission and overcoming barriers to disclosing their HIV status to their partners.
UM professor of psychology Steven Safren, Ph.D., and other UM collaborators, recently published a study in The Lancet HIV journal that linked depression to lower HIV drug adherence and also showed that integrating cognitive behavioral therapy with specialized counseling helps boost adherence.
“While HIV medications and drug prevention mechanisms have greatly improved, it can still be difficult for some to benefit from those drugs due to mental health issues that worsen adherence,” said Safren. “Evidence-based mental health interventions help patients overcome the psychological burdens of the disease which in turn helps boost their adherence and their overall health outcomes.”
UM has also made significant strides in HIV research, testing, outreach and care in the following areas
A project led by Sonjia Kenya, Ed.D., M.S., M.A., Director of Community Health Programs at Sylvester Comprehensive Cancer Center’s Jay Weiss Institute for Health Equity, conducts rapid street testing in African-American and black Caribbean neighborhoods. Funded by the Elton John AIDS Foundation, the project aims to increase knowledge of HIV transmission and treatment among African-American and Caribbean black adults in Miami, and reduce risky behaviors among program participants. The program builds on Kenya’s previous studythat showed the use of community-based health workers along with rapid, home-based HIV testing is an effective strategy for getting more high-risk African American residents tested and connected to health services and treatment.
Innovative Lab Research
Adding to existing clinical research and lab studies, the University became an HIV research hub with the addition of Stevenson and two other world-renowned infectious disease scientists, David Watkins, Ph.D., professor and Vice Chair for Research in the Department of Pathology, and Ronald Desrosiers, Ph.D., professor of pathology. In 2015, Desrosiers and his Harvard University collaborators identified an antibody-like molecule that provides long-term protection against HIV/AIDS infection. Researchers engineered molecules which blocked two key receptors that the HIV virus uses to gain entry to the body’s CD4 white blood cells. The study showed that 100 percent of HIV-1 strains were neutralized by this new molecule inhibitor, which is the first time that this level of protection has been accomplished.
Women’s Interagency HIV Study
As minority women are disproportionately affected and represent the majority of new HIV cases, the University became a site for the national Women’s Interagency HIV Study. Funded by an $8.5 million National Institutes of Health grant, the five-year study has a broad focus including epidemiology, social and behavioral issues, substance abuse, long-term impact of HIV medication, prevalence of co-infection with other opportunistic diseases, such as hepatitis B and C, early onset of menopause, vaginal health and other scientific insight. In a recent and significant finding, Fischl and her collaborators found that vaginal douching increases the risk for women to contract HIV and transmit it to their partners. Douching, researchers found, breaks down the vaginal cell structure and causes bacterial vaginosis, which leaves women more vulnerable. For HIV-positive women, it causes increased amounts of the virus to form in the vagina, particularly around the cervix, which increases chances for transmitting the virus to their partners.
Partnering with Jackson Memorial Hospital, University of Miami Health System doctors created a comprehensive HIV clinic designed to be a one-stop-shop clinic for all the patients’ needs, especially those of low socioeconomic status. The unique center provides a range of medical and advocacy services and, partnered with the UM School of Law, provides a legal clinic at the site.
The teen and adolescent population (13-24) has become a primary target for UM’s local outreach efforts. Many are unaware of their status, or if positive, are unable to disclose to family members. Miller School outreach workers in the Division of Adolescent Medicine have become the foot soldiers of outreach and have mounted creative tactics to reach youngsters—from setting up mobile testing clinics to staffing health fairs outside of alternative night clubs and high school sporting events. The clinic itself and the group sessions for those newly diagnosed have become a safe haven for youth who can get comprehensive care, interact and confide in others like themselves.