Kaiser Permanente’s 34th Annual National Diversity Conference, held recently in San Francisco, culminated in the presentation of the HIV/AIDS Diversity Awards, along with White House policy advisor Greg Millett’s battlefront assessment of the 30-year war against the disease in the U.S.
Millett noted the year-by-year drop since the 1990s of new HIV cases and a decrease in the public’s alarm over the disease. He contrasted that success with the continuing problem of delivering adequate care for the poor and minorities in urban areas where the prevalence of HIV is still high.
Bringing care to these victims is crucial, he said, because many studies show that beginning to treat an infected person in the early stages of HIV reduces the risk of transferring it to another by 90 percent or more.
“The road to treatment in the U.S. is fraught with difficulties,” he told the audience. “This is nothing new to any of us.” Millett, who is also a researcher at the Centers for Disease Control, lauded the Kaiser Permanente study published in 2009 that showed the risk of dying from AIDS didn’t differ between ethnic groups when there was equal access to care.
“You don’t see that nationally,” he said. “Kaiser Permanente is doing a very good job of suppressing HIV. This is exactly what we would like to see happen nationally.”
Millett’s words were well-received by Dr. Michael Horberg, Kaiser Permanente’s national director for HIV/AIDS, who announced the Diversity Award winners and was on stage with Millett and Diane Gage-Lofgren, senior vice president for KP Brand Strategy, Communications and Public Relations.
Appointed to Obama’s Presidential Advisory Council on HIV/AIDS in 2010, Horberg hopes to make Kaiser Permanente’s best practices a part of national policy. Practicing at Michael Reese and Northwestern Memorial hospitals in the Chicago area for 10 years before coming to California, he has spent most of his medical career in the fight against the disease.
He is one of those lucky people whose life both on and off the job is fueled by a strong sense of purpose. In the early 1980s, as the first patients infected by the HIV virus were being treated at Boston City Hospital where he was in his third year of medical school, he already knew he was gay, but it was still a little too early for him to declare himself.
“It was the fear of rejection, the fear of being ostracized, even in the medical community, of not being able to attract any patients,” he recalled.
Ironically, the onset of the AIDS crisis is what finally helped to liberate him. As patients with HIV symptoms, including some of his close friends, began coming to him in private practice, he realized stepping out of the closet would help them get the care they needed and allow him to be a more powerful advocate for specialized care.
The timing was good.
“There was no hiding any more. I was true to the world and it was true to me,” he wrote in California Medicine in 1997. “And it paid off in a number of ways. For one thing, because I was a gay doctor with a large gay and lesbian patient population, Northwestern Community Medical Group (affiliated with Northwestern Memorial Hospital) invited me to merge my practice with theirs. And because I had a high patient satisfaction rating, managed care companies came courting as well.”
Dr. Horberg began specializing in HIV care in Chicago where he grew up. Early on, he knew he wanted to be a doctor. Both the science and the humanism involved appealed to him, and both values were part of his family heritage. His uncle was a physician and a great-aunt had attended medical school and practiced in the 19th century in Estonia and the Ukraine.
Being able to help his gay and lesbian brothers and sisters has fulfilled that early desire to meld technical skill with compassion. Especially early in the crisis “when there was a limit for what we could do for patients, really caring, really showing love was critical,” he said.
Both the science and the compassion have continued to motivate Dr. Horberg in his work: He was an early proponent of experimental drug trials and has devoted much of his research to improving the delivery of care as well as exploring the source of the disease.
Horberg was recruited by Kaiser Permanente for his work with HIV and was happy to leave the muggy hot summers of Chicago in 1996 for the Bay Area’s temperate climate. He worked briefly at South San Francisco before taking charge of the HIV/AIDS program at KP Santa Clara where he handled patients, began his work as a scientist in Kaiser Permanente’s Division of Research while studying for a master’s degree in research at the University of California at San Francisco.
He has since worked on numerous studies using data from the records of 50,000 HIV patients who have been treated by Kaiser Permanente since 1981. His studies have focused on many aspects of caring for HIV patients, from the management of antiretroviral drug therapy and allied infections to issues of ensuring quality of care and equal access to care.
Dr. Horberg collaborated on the study that sought to determine whether equal access to care would result in a similar outcome for HIV patients of different races. The study — lauded by Millett in his remarks to the Diversity Conference — was the first to break out statistics for Hispanics and it found no disparity in the clinical outcomes between white, black and Hispanic KP patients, with Hispanics having a slightly lower mortality rate.
During his years in California, he was a tireless advocate for HIV patients in his roles as physician, researcher and leader of initiatives to improve and standardize care. Horberg chaired the central research committee for the Northern California region, and led the HIV Interregional Initiative.
Last year, working with the National Committee on Quality Assurance (NCQA) and other interested groups, the HIV Initiative developed 17 measures for quality HIV care — including patient retention, screening and prevention for infections, immunization, and initiation and monitoring of antiretroviral therapy — that are intended for nationwide implementation.
“We really have done a very good job,” he says of Kaiser Permanente. “We can do better. We are not going to rest on our laurels. We know where there is room for improvement. . . We are willing to analyze our care. We are the first managed care organization to develop a set of care metrics. And from that we asked our other research questions that have led to policy changes. We have really compassionate care. We give a damn.”
Early this year, Dr. Horberg moved to Maryland to become executive director of research for the Mid-Atlantic States Permanente Medical Group. Dr. Horberg had to let go of seeing patients when he made his move to the east and that was hard to give up, but leading research, his other love, is also about people, he says. “The science we do at KP is the science of caring for patients and how to do that in the most effective way is really what we study.”
Fortunately, he left with his true love, husband Chip Brian Horberg, whom he married in 2008 while gay marriage was legal in California. The couple, whose birthdays are July 10 (Chip) and July 12 (Michael), were married July 11 under a traditional Jewish huppah on the rooftop of their condominium in San Francisco, surrounded by family and friends, including a large contingent of Kaiser Permanente colleagues.
This is the first of two articles about Kaiser Permanente's response to the HIV/AIDS crisis. There's more about KP's history of taking care of HIV/AIDS patients at the Center for Total Health.