Gregg Masters 00:06
PopHealth Week is brought to you by Health Innovation Media. Health Innovation Media brings your brand narrative alive by original or value-added digitally curated content or omnichannel distribution and engagement. Connect with us at www.PopUpstudio.productions and welcome everyone. I’m Gregg Masters Managing Director of Health Innovation Media and the producer and co-host of PopHealth Week. Joining me in the virtual studio is my partner, colleague and lead co host of pop Health Week Fred Goldstein President of Accountable Health, LLC. On today’s episode of PopHealth Week, our guest is Leandro Mena MD MPH a clinician-researcher and public health advocate with expertise in the prevention and clinical management of sexually transmitted diseases and the human immunodeficiency virus in STD/HIV prevention research, we explore the many layers of public health within the context of the Covid 19 pandemic. Among the many insights he offers. Dr. Mena reminds us that public health encompasses more than the lessons of the recent pandemic, emphasizing the continued prevalence of STD/HIV threats, progress and prospects. Dr. Mena is the founding Chair of the Department of Population Health Science at the University of Mississippi Medical Center, John D. Bower School of Population Health and Professor of Medicine in the Division of infectious diseases. He also directs the Center for HIV/AIDS research, education and policy at the Myrlie Evers-Williams Institute for the Elimination of Health Disparities, and serves as the STD Medical Director for the state of Mississippi. And with that introduction, Fred over to you help us connect with Dr. Mena’s. innovative work.
Fred Goldstein 00:07
Thanks so much, Greg, and Leandro, welcome to PopHealth Week.
Leandro Mena 02:06
Thank you. Thank you for having me here.
Fred Goldstein 02:08
Yeah, it’s a pleasure to get you on the show. And finally, have a chance to talk to you some more. So why don’t you start by giving our audience a little bit of your background?
Leandro Mena 02:15
Oh, sure. You know, I’m, I’m an infectious disease specialist by training, I trained in infectious diseases in New Orleans. And before that, I did residency in internal medicine. For the past 20 years, having almost 20 years I’ve been in Jackson, Mississippi, I came originally to be director of the local STD clinic with the health department. So my work here has been largely a in the, in the in the field of sexual health, STDs, HIV prevention, and under for for the past 10 years, perhaps, you know, he has really been involved in, in thinking through, you know, how we deliver care to people, and, and developing, you know, thinking about healthcare delivery models that are responsive, and are informed, you know, by past experiences, and by preference of the patients that we see.
Fred Goldstein 03:12
And you’re obviously in Mississippi, an area in which health issues and health disparities tend to be rather large, obviously, HIV is an as a disease that impacts disproportionately those the minority communities. I know, you’ve done a lot of focus work in that how is that coming along? Now?
Leandro Mena 03:28
Fred, we have done tremendous progress. I mean, it’s almost difficult to believe that this June, we celebrate the four years of that MMWR report by CDC that basically, you know, a report on the first, you know, cases of AIDS in the United States. And on those four years, they know a, we have been able to decrease the number of HIV infections, at least domestically, substantially from from a where it was in the peak of the early 90s. Right, about 180,000 new infections per year to where we are now to less than 38,000. I think that in the past since for testing for 2018, we have our 8% decrease a and, and we have, you know, a a, we have a new strategy, a the ending the HIV epidemic strategy that aims to reduce by 75%, the number of new HIV infections in five years, and by 90%, the number of new HIV infections in 10 years.
Fred Goldstein 04:31
Wow. And so, you know, I think back to the early days, obviously, this was a disease originally of gay white men, men, and then it expanded out and now what where is that in terms of infections between various communities, men, women, different races, etc.
Leandro Mena 04:47
So, so HIV, you know, at least in the United States, a still you know, is a disease that disproportionately affect you know, certain populations such as geography in terms of geography, you know, the South that only has 38% of the population has about 50, a llittle over 50% of all, you know, HIV cases, when it comes to race, you know, African Americans are disproportionately affected by HIV, a another, you know, Latinos, you know, then when it comes to risk Men who have sex with men are, represent only 2% of the US population and represent almost 70% of all new HIV infections. I mean, I cannot imagine any other health disparity right, you know, bigger than the one that exists, you know, with HIV, I see the effects, you know, men who has sex with men me,
Fred Goldstein 05:40
and obviously, you’ve talked about we’ve made great progress in reducing that number of infected every year, but we’re still shooting to reduce it even more, and I know there are newer treatments that come out, have come out, can you talk about PrEP, what that is and how that is used?
Leandro Mena 05:54
Well, absolutely, you know, in a for, you know, since 2002, almost, you know, again, 10 years ago, the FDA approved, you know, a drug, you know, tenofovir combined with emtricitabine that was the first you know, PrEP medication approved now there are two, you know, formulation available tenofovir with a alafenamide a or tenofovir disoproxil Fumarate, there are two co-formulations available, that are at the end, you know, one pill that people can take once a day. And if you take one pill once a day, that really, you know, significantly reduce your risk of becoming HIV infected is exposed to over 99%. You know, they tenofovir disoproxil fumarate plus, emtricitabine, which is co formulating one single tablet, you know, can be taken by men who have sex with men, heterosexual individuals, people who are maybe at risk of HIV because they inject drugs and share needles or or paraphernalia, and that, you know, pill can actually, you know, significantly reduce the risk of HIV infection.
Fred Goldstein 07:01
So, and I guess we probably should explain PrEP is,
Leandro Mena 07:06
right PrEP, as you know, again, it’s a strategy.
Fred Goldstein 07:10
It’s Pre-exposure Prophylaxis , right?
Leandro Mena 07:12
Right. It’s pre-exposure prophylaxis, correct. And it’s a strategy that consists of taking, you know, medication antiretrovirals, right, that are very often used for the treatment of HIV, a by individuals who are not HIV infected who people who don’t have HIV, so they don’t get HIV infected, exposed to HIV. So that’s a really important clarification in the way I A helps explain people the analogy, right? It’s almost like birth control, right? birth control is taking the oral oral birth control is a pill that women take, you know, every day. So if you know exposed, right, they can prevent, you know, unwanted pregnancy. In addition to PrEP, there is another strategy that uses antiretrovirals to prevent HIV, and it’s called post-exposure prophylaxis post after after exposure , which I equate, you know, to how it works The Morning After Pill, you know, if you have an accident, if you think you may have an exposure of HIV, you have, you know, unprotected sex, you know, with someone who may be living with HIV, then you can take, you can start within 72 hours, you know, and cocktail of whichever medication that you take for four weeks, and that will reduce again, similarly, the risk of acquiring HIV
Fred Goldstein 08:29
and how large a reduction is that
Leandro Mena 08:32
so, with post-exposure prophylaxis, we don’t have human data I’m part of the reason is because, you know, it will be unethical, right to randomize people, you know, well, yeah, that’s evil, you know, so that we only know from animal data is very effective. And then from historical data that we have not seen anyone who has taken post-exposure prophylaxis, you know, a properly and completely four weeks will not become HIV infected, in fact that there is another tremendous advance, you know, in HIV prevention, you know, people, not everyone knows that individuals who are living with a diagnosis of HIV, who take their medication every day. And as a result of taking their medication, their viral load, the amount of virus, you know, that is in their blood, becomes undetectable, cannot, absolutely cannot pass HIV to someone else. I mean, I will argue that the most effective method that we have nowadays, to really prevent HIV transmission is actually you know, making sure that those individuals who are living with HIV are being treated, you know, for the infection or taking the medication every day. What happens that will happen is that, unfortunately, right, you know, in the United States, you know, not everyone who’s living with HIV is aware that they are their diagnosis, so we’ll have to improve testing. Not everyone who is aware of the diagnosis, you know, has had the opportunity to see a provider or see a person who can prescribe medications to them on a regular basis, and even if those medications are prescribed. Not everyone, you know, has the ability to take those medications every day. You know, there are many factors, I mean, sometimes education, sometimes other priorities in life, sometimes, you know, changes in insurance, a changes in job, there’s so many factors that really you know, has the potential to interfere in people’s ability to take medication every day. One thing that is exciting, I think, is that we have new ways to treat HIV coming down the pipe, you know, a, the FDA approved this year, the first injectable method to treat HIV. So we’re talking about instead of people taking a daily pill, that sometimes good news, bad news may affect, you know, your ability to do that. Now, very soon we will have an injection, we have an injection that is already approved or is available now it’s going to be available, that people can have once a month, that will replace the need to take daily, you know, oral medication.
Fred Goldstein 10:59
You know, I think back 20 years ago, when I was doing some work with HIV disease management programs, and it’s a classic population health issue, you’d have multiple ways to treat, to keep people from becoming infected pre and post, and then you have all the issues associated with adherence and lifestyle and social determinants of health. And really, you’ve got a fairly substantial practice in the state of Mississippi, you know, which is an area that struggles with a lot of these issues, how have you seen that going in that state?
Leandro Mena 11:29
You know, Mississippi, like the rest of the south itself has unique challenges. I mean, it’s a long list, I mean, I think, you know, a, you know, a racism and the impact the legacy of racism, right? in communities, you know, the poverty, the lack of education, the fact that so, many states in the south, you know, did not expand Medicaid, and we have such a large proportion of uninsured individuals, they hide the fact that, you know, public transportation, right, is so ineffective, you know, in many, in many, the fact that public transportation is so ineffective in many metropolitan areas, but also there is actually you know, lacking, you know, the lacking in many other suburban areas, the fact that, you know, such a large proportion of individuals who are living with HIV in the south, libe in rural areas, right, so all that really, you know, contributes, you know, to the, to the, to our reality, you know, that taking care of HIV in the south, you know, Mississippi, Alabama, Louisiana is a lot harder, it’s a lot more space, taking care of HIV in a large metropolitan area, a states like Alabama, Mississippi, over 50% of all the individuals living with HIV live in rural areas. So then you have to imagine what is said, you know, to live in a rural area, we means that sometimes, you may have a clinic nearby, but that can be nearby, maybe the clinic where your family works where your best friend or cousin works, you know, I mean, so it’s not only about access, but it’s about having access that people can use. So it’s a tremendous challenge.
Fred Goldstein 13:11
Wow. And I know that the university itself, there is one of the two HHS Centers of Excellence for telehealth. Have you implemented any telehealth with HIV? Or is that something you’re thinking about for those rural communities?
Leandro Mena 13:23
Well, no, it certainly, you know, I think telehealth, you know, has been again telehealth a tremendous tool, you know, and we failed, it should be a tremendous tool right. And, and, and before COVID, I think COVID accelerated right, the implementation of telehealth and we learn you know, a lot of a through COVID because, when it comes to caring, you know, I think that one of the things that we have to understand is that there has been tremendous innovation you know, with COVID you know, and there has been tremendous innovation about how to deliver health services in a way that is easy, you have drive through you know, laboratories, you have drive through vaccinations, you have you know, a use of telehealth, but all that, if we do not figure out a way process by which we give people a we we give people an equitable you know, access, right? It has the potential to improve disparities. So, I mean, let me give you an example of a for example, state like Mississippi there are so many rural areas who do not have broadband. You know, when I started doing telehealth about three years ago, for pre-exposure prophylaxis, the mean, again, as a way to bridge the lack of access to culturally competent providers, you know, for gay bisexual men in rural areas. A one of the things that happened is that the most common place where people will connect with me from their phones, right to do a telehealth visit was the parking of Walmart. So I say so I start wondering you know, is it because people are leaving home so that you have privacy? And I start asking people and the reason why is because that’s where people can get Wi-Fi. Right?
Fred Goldstein 15:06
wow
Leandro Mena 15:06
So if you want to have a video conference, a video conference of 30 minutes, will use one gigabyte of data. I mean, so again, you have to have a data plan in order in order to have the Telehealth. So so it becomes complicated. A second thing is, when you talk to, and I have done focus groups, with many of my patients who are living with HIV, to help us understand how these things work for them, you know, one of the things I learned is that a large proportion of our patients, especially during COVID, you know, do not have at home the privacy, you know, that they need in order to have this, you know, medical visits, you know, so in the past, they were able to go to a local, you know, library, you know, but because of COVID, many of these things were close. So again, a I think that telehealth is a tool, and one of the things I learned that patients really like, you know, be able to access telehealth when they need it. And when they need it means that if you have to go to a doctor, but you have to take your kids, you know, to school or you have to go to work, yes a telehealth call, you know, may simplify things, and it’s easier. But when you have time to see your doctor, as you know, you want to see your doctor, you know, you know, that’s what you want to do. You know, so I mean, again, I think that again, telehealth will be part of the tools that we use to improve access. And not like a one size fits all, you know, to simplify our own, you know, a operations as providers,
Fred Goldstein 16:29
right? So in essence, it’s it’s similar to the whole redlining issue in terms of adequate access to the technology, the broadband, the bandwidth, etc, to be able to use these services. So if we don’t build that into the backside of this thing, it’s not going to help these populations that need it desperately.
Gregg Masters 16:47
If you’re just tuning into PopHealth Week, our guest is Dr. Leandro Mena, the founding Chair of the Department of Population Health Science at the University of Mississippi Medical Center, John D. Bower School of Population Health and Professor of Medicine in the Division of Infectious Diseases, and the director of the Center, HIV AIDS Research, Education and Policy.
Leandro Mena 17:13
Absolutely,
Fred Goldstein 17:14
yeah, fascinating. As you look at what’s happened, you’ve talked about the the progress, what are what are some of the initiatives to try to drop that, you know, 75% in five years, 90%, or whatever, in 10? What are some of the things that they’re considering as ways to do that,
Leandro Mena 17:30
you know, someone say, you know, our past is a prologue, you know, to the future. And I think that if you look at the rate at which we have been able to decrease, you know, the number of HIV infections, right, in the past 10 years or so, you know, that tells us that we have to do things that are innovative, we have to do things very different from what we have done, if we’re going to achieve the goal of decreasing HIV infection by 75% in five years, if I look at the last five years, from 2014 to 2018, we only decreased HIV infection by 8%. So we have to go to 75. That means that we have to work maybe nine times harder, right? You know, so so so it requires a lot of innovation, a lot of thinking out of the box, a lot of really being able to do things in a way that we have never done before. So part of this I mean, when you deal with a disease like HIV, that is, again, an important factor, you know, is stigma, you know, that a aggressive homophobia, a that affects individuals who are vulnerable, who are uninsured, who very often have lower socioeconomic status, you know, lower educational attainment, and you think about the healthcare system or trying to care for these individuals, then you have to question right? That if we have the right delivery models, I mean, to address the needs of this population, one of the things that we’re doing that really was inspired in part was the University of Washington the Matt Golden, and Julie Dombrowski did a with a max clinic in Washington, in Seattle, is that we have developed this low barrier access clinic, you know, they what we say is that healthcare in the United States is like an upslope, right. And if you can climb that slope, then you will enjoy, you know, health and wellness, but that to climb that you need to be equipped by a number of things, you need to have probably, you know, health insurance, right, you know, to be able to afford, you know, copays, you know, to be able to have a job, probably, that will give you paid make a living so you can attend appointments, you need to figure out how to call, make appointments, you know, cancel appointments, you need to be able to set up, you know, I call the pharmacy request refills, you know, so all the things that seem to be intuitive, you know, if you have been doing that for some time, but are totally foreign if you are a man, you know, who only goes to the doctor when something hurts, something burns, you know, or something breaks. So one of the things that we’ve been doing is that we develop this low barrier access clinic, let’s say, you know what, you know, let’s we combine high-intensity case management, we say, we tell the clinics, you know, give us our the patients that you have, that instead of you doing the best that you can are not doing well, I mean, and we sit down with those patients and we do an intake where we ask people what happened when or was happening until now, trying to trying to understand people’s past experiences, within you know assess people needs, you know, both clinical and social needs. And then we ask people, we try to understand what are people’s expectations? How they would like this to work better? How can we do better for you? See, I mean, you want another case manager, you want to case manager who calls you more often? you prefer to be call on the phone? Do you prefer to be text messages? You want those every day? A Do you transportation? How do you prefer? I mean, is it I mean, is that taxis? Okay, we’ll learn by when you give people choices. And you ask, you learn that some people don’t like, you know, strangers to go to their house. And it’s because the moment that someone come in the neighborhood that no one knows, everyone is looking, what we did, is that we can read up appointments, I mean, with people, you’d listen, just show up whenever you can, he doesn’t really matter. We also provide financial incentives to not to pay people but to be able to compensate people to mitigate the social for the social determinants of health, with the assumption that if you don’t have paid medical leave, and you go to a place you take time off from work, probably you’re losing income, right? You know, so again, for many of our patients coming, showing up for a medical appointment is expensive, and they couldn’t come, but they can because they cannot afford health. So that’s kind of the rationale. Besides besides that,
Fred Goldstein 21:42
you know, I know people can’t see this, because it’s a podcast, but I’m smiling ear to ear listening to you Leandro. Because in essence, you’re, you’re identifying all of those issues, people can’t focus on their health because their life gets in the way.
Leandro Mena 21:56
Right?
Fred Goldstein 21:57
Try to find those life issues and figure out how do we solve this? How do we solve that in very unique and individual ways, which is just exciting to hear about? I think that’s really the key that’s a population health approach to a disease state and the clinic to help people beyond just their health.
Leandro Mena 22:13
I think, you know, it’s a reframing. I mean, I see that as really true, you know, patient-centered care, you know, that I call individualized, I mean, a health care delivery, you know, so we want to make sure we have a team that is absolutely amazing, you know, people who’s very caring, empathetic, who really connect with patients, again, to say, listen, we’re doing this together. I mean, how can we do this better? How can we do this, you know, to work for you.
Fred Goldstein 22:39
Fantastic. It really is fantastic to hear this in the progress that’s been made. And obviously, hopefully, we we as a country achieve those goals and exceed the ones you talked about of dropping it by 75% in five years and 90% in 10 years. I think the tools are there. And obviously approaches like you have, can do that. The other role you play at the university, is you’re the chair of the department of population health, correct.
Leandro Mena 23:03
The Department of Population Health Science.
Fred Goldstein 23:04
Yeah, population health science is correct. Because there’s this population health science, I think there’s data and analytics, and there’s another one in there.
Leandro Mena 23:11
preventive medicine.
Fred Goldstein 23:12
Yeah, that’s it preventive medicine. And I’m still learning all this stuff. I’ve been there for a little while. So can you talk about the school and what the school does the Bower School of population health, your role, and what the school does?
Leandro Mena 23:25
right No, absolutely. You know, they they John D. Bower School of Population Health is actually the, the newest school in the University Mississippi Medical Center campus, the newest professional school, and the school was founded about four years ago now, with an endowment of the Bower foundation to really, you know, address the disparities, you know, and improve the health of all Mississippians consistent with the mission mission of the University of Mississippi Medical Center. So in from its, the school has our three departments. One department is preventive medicine, the other department is the department of data science, and the third department is department of Population Health Science, you know, this population health show and show your audience, you know, kind of understands, I’m assumed that they understand what population health is. And I always tell people that population health science is the discipline interdisciplinary, you know, right, a science that really focus in the understanding of the mechanisms by which disparities exist, you know, and how, you know, equity can be achieved. So, we are very, you know, amazing, diverse group of faculty, really diverse backgrounds, that makes you know, the work that we do, really group of people who really think out of the box that really draws from different you know, from different fields, you know, I have faculty whose background is in criminal justice and education, people urban development a politics and economics, public health, clinical outcomes, you know, physical exercise, physical activity, translational researchers, say, epidemiology society Really, you know, true, you know, a yourself, you know, health care management. And so it’s a really diverse group of individuals, I mean clinicians, so it’s very, very diverse and everyone thinking, you know, both in the upstream, you know, a factors that influence a, a health outcomes in populations.
Fred Goldstein 25:20
And people who want to get a Master’s or an executive Master’s or a PhD program can do that through the school?
Leandro Mena 25:26
Absolutely, that the school has three academic programs, one of the things that we have a master’s in population health, is that two years is that we call that traditional progress or two years program, but it’s an online asynchronous program that is very suitable for people to do, even when they have, you know, their job. So we have then a traditional Ph. D. Program, which is a four-year minimum program, a, there is an in person program, the population health program, health science, you know, PhD, is a program that really focuses on developing population health scientists, we want to make sure that I tell students and potential students that, that I see the progress a transformation process, right, what the process is to them process where they come in, and they exit the program, as a population health scientists. We take no more than four students per year because we want to make sure that we have the faculty and we have the capacity to really mentor in in, in nurturing, you know, each one of those students into the process of becoming a population health scientist. And then we have our stellar program of population health management that you know, very well, as you were one of the founder faculties in our program that really the focus on on is an executive program in program in science, a Master’s in Science in population health management, that really focus on making sure that clinicians and other healthcare professionals have a clear understanding of our healthcare system, the challenges as we envision the opportunity to be part of the a reinvention of our healthcare system. I think that, you know, the United States has impending, you know, a crisis in addressing healthcare, as the proportion of our national GDP, you know, a that is dedicated to health continues to increase every year, at some point, we’re gonna have to address it, we can no longer be the country that spends the most in health care, yet, we don’t have health outcomes that really correlate right with the kind of expenditure and investment that we make.
Fred Goldstein 27:30
Well, it’s fantastic. It’s been great having you on the show, Leandro, thanks so much for the discussion on HIV/AIDS, and the progress that’s been made there, and also introducing the Bower School of population health. It’s a pleasure working for you, actually, in my role there. And I really appreciate you coming on PopHealth Week.
Leandro Mena 27:46
Thank you so much for the opportunity. I really enjoyed and thank you for inviting me on the program.
Fred Goldstein 27:51
Back to you, Greg.
Gregg Masters 27:52
And thank you, Fred. That is the last word on today’s broadcast. I want to thank Dr. Leandro Mena the founding Chair of the Department of Population Health Science at the University of Mississippi Medical Center, John D. Bower School of Population Health and Professor of Medicine in the Division of Infectious Diseases for his time and generous insights today, for more information on Dr. Mena his work go to www.umc.ede/SOPH or follow the school’s work on Twitter via @BowerSOPH and @UMMCnews respectively. And finally, if you’re enjoying our work here at PopHealth Week, please consider liking and subscribing to our channel on the podcast platform of your choice and do follow us on Twitter by @PopHealth Week. Bye now.