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to Section One | to Arts & Entertainment
posted Friday, February 1, 2013 - Volume 41 Issue 5
ASK DR. J: The Cascade, not the local mountains
Section One
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ASK DR. J: The Cascade, not the local mountains

by Dr. Joanne Stekler - Special to the SGN

This article is part of a series focusing on HIV and other STD prevention and care topics for Gay/Bisexual men and Transgender individuals in Seattle and King County.

Lately, there's been a lot of talk in the HIV field about the 'cascade.' In nature, a cascade is a small waterfall that flows down a mountain slope in steps. In HIV care, it's a way to look at how we are doing as a community to get care and treatment for people living with HIV (see figure). For people living with HIV, there are four steps in the HIV care cascade: knowing your status, getting into care, staying in care, and getting to an undetectable level of HIV in your blood.

The Centers for Disease Control and Prevention estimates there are about 1.1 million people living with HIV in the U.S. Of those, about 80 percent know they are infected, and the other 20 percent are still not aware of their status. Only people who know their status can take the next steps to take care of themselves. That's why Public Health - Seattle & King County is promoting more frequent testing, so more people know their status.

If you've been diagnosed with HIV, the first step is to get into care - to be seen by a doctor or other provider who can monitor your HIV infection and talk with you about treatment options. You might hesitate to see a doctor for a variety of reasons - it's hard to face the diagnosis, you're worried about how much it's going to cost, or you're afraid someone might see you walk into an HIV clinic - but it's the most important first step. About 20 percent of people living with HIV know they're infected but haven't seen a doctor. If you're HIV-positive and not seeing a doctor regularly, then you're not getting the care you need.

TEST FREQUENTLY
The next step down the cascade is the number of people living with HIV who stay in care after that first visit. This means going to see your provider and getting blood tests every three to six months. People can fall 'out of care' for a lot of reasons. Maybe it's the money for co-pays. Or substance use or depression is getting in the way of taking care of yourself. Or you've moved and don't know how to find a new doctor. Or things get too busy with work or school. Again, I don't mean to be a nag, but there are places that can help you with anything that gets in the way of sticking with your medical care. Check out Public Health Seattle's guidebook, Now That You Know, to find help. It can be downloaded at www.kingcounty.gov/healthservices/health/communicable/hiv/publications.aspx.

Finally, the last step down this cascade is the number of people living with HIV who have an undetectable level of HIV in their blood. That means you're on HIV medicines, you're taking them as prescribed, and blood tests show they're working. HIV medicines can help you live longer and decrease the chance of passing HIV to others. Meds can also decrease the 'community viral load,' the average level of HIV in the community. With a lower level of virus in the community, we believe it's less likely someone else will get infected with HIV. Now that we've taken all these steps down the cascade, look where we ended up - only about a quarter of all people living with HIV in the U.S. are taking meds and have a suppressed HIV level.

SEATTLE'S SUCCESS
But you can see from the black bars in this figure that we're doing a whole lot better in Seattle - over half of the people living with HIV in Seattle have a suppressed HIV level. Part of the explanation is probably different characteristics of people living with HIV in Seattle compared to the rest of the country. And part of it is probably the great network of providers who take care of and support people living with HIV here.

But we still have some big steps to take so we can flatten out this cascade.

If you're an HIV-negative guy who has sex with other guys, you can get tested for HIV and other STDs at Public Health's STD Clinic, Gay City, the baths, or your doctor's office. For hours and locations for these and other places that do HIV testing, call (206) 263-2000 or go to www.FindYourFrequency.com. You can also use this website to find the testing frequency that's right for you and sign up for testing reminders.

If you're HIV-positive but don't have a doctor, please call the One-on-One program at (206) 744-4377 to make an appointment to see one of our doctors. One-on-One is free. If you already have a doctor but it's been a while since you've been in, call them now to make an appointment. Set up a reminder in your calendar or on your phone to help you make and keep appointments regularly. And talk to your doctor about taking HIV medicines and how to make them work for you.

Joanne Stekler, M.D., M.P.H., is deputy director of community services for the HIV/STD Program at Public Health - Seattle & King County. She is also an internal medicine and infectious disease physician at Harborview Medical Center and an assistant professor of medicine and epidemiology at the University of Washington.

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