Joseph McGowan, MD, FIDSA, FACP, AAHIVSNorth Shore University Hospital
Manhasset, New York
Joseph McGowan has been treating people living with HIV for 30 years. He completed his undergraduate studies at Columbia University, studying there at the same time as President Obama. McGowan earned his MD from Mount Sinai School of Medicine in New York City. He did his Infectious Diseases Fellowship at the Albert Einstein School of Medicine and also completed an NIH Fellowship in Immunology. McGowan was very interested in immunology; in how the host interacts with infections and illness. McGowan recounts, “Initially I planned to focus on tuberculosis because I had witnessed its varied presentations and impact. I did my early training in some of the municipal hospitals in New York City where TB was common among recent immigrants. During that time, the mid-1980s, HIV was beginning to hit hard and I saw that this disease was causing such an imbalance in the immune system that it left its victims unable to fight off the unusual infections that were rare or unseen in normal hosts and that other aspects of the immune system were in overdrive; high levels of allergies, sinusitis, skin disease, etc. Tuberculosis was also going along for the ride and became rampant in the inner cities. It was exceedingly clear to me that I wanted to be on the front lines to try to understand the cause of this condition, and, even more importantly, to offer help to people afflicted. There was a group of very dedicated, brilliant clinicians treating people at clinics in the inner city in New York. It was a great pleasure to work along with them. Clinicians had to think out of the box, try whatever it took to slow down the infection, throw down some roadblocks and buy some time; hopefully healthful time; for the young people facing what was a bleak prospect.”
For many years McGowan worked in the South Bronx, an epicenter for the HIV epidemic in the Unites States. The populations were challenged by poverty, language barriers (many Latin American and West African immigrants), cultural and educational barriers. McGowan saw HIV/AIDS as a truly opportunistic infection in that it targeted the most vulnerable populations in regards to access to care and the ability to negotiate complex medical systems and, eventually, treatment. Says McGowan, “I learned more from making home visits to my patients in the South Bronx than I could have ever learned in any classroom about what people with HIV have to deal with and the obstacles that must be overcome in addition to the challenges of being adherent with complex treatment regimens, which is no cakewalk in its own right. One thing that a mentor taught me that has always stuck with me was that, as we were working with a very vulnerable population which was often hit earlier and in a harder way by epidemics, as well as chronic diseases, we had an obligation to witness and report what we were seeing. It had value for our colleagues. In that vein, we were seeing high rates of HIV infection among pregnant women in the early 1990s. As therapy started to evolve and ZDV was becoming accepted for prevention of Mother to Child Transmission (MTCT) of HIV, we started to adopt combination ARV among pregnant women, which greatly reduced transmission. Our results were very encouraging and helped inform studies on combination therapy during pregnancy. In fact, I was in Uganda at an international conference on prevention of MTCT of HIV on September 11, 2001 and watched the horrible events in the US unfold from a hotel lobby in Kampala.”
Today, McGowan is in practice with the North Shore University Hospital Center for AIDS Research and Treatment located on Long Island, near New York City. They provide HIV primary care to over 2,000 people living with HIV/AIDS in two clinical sites. They have a multidisciplinary program with 13 Infectious Disease doctors, a physician assistant and nurse practitioner; a gynecologist, two part-time psychiatrists, RN and social work case managers for all patients. They offer mental health therapy and utilize a nutritionist, three health educators, substance abuse therapy, group and individual education, legal aid, transportation support, a specialized pharmacy, HIV clinical trials, dental care, HIV testing, STD screening and treatment, post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). They have achieved NCQA recognition as a Level 3 Patient Centered Medical Home for HIV.
McGowan treats patients from urban, suburban and rural areas; each facing unique challenges. Over 40 percent of his patients are women, over half are either African American or Hispanic, and about a quarter to a third are men who have sex with men (MSM). Says McGowan of his patient population, “We have been very busy seeing an explosion of new patients over the past one to two years; several new patients each week. Our new cases are from across the spectrum, but especially young MSM and middle-aged women. About 53 percent of our cases are over the age of 50.”
“Without a doubt the most rewarding part of my job is when I am in the room with my patient, door closed, discussing what is going on with them and, hopefully, supplying them with education and tools to motivate them to adopt and maintain health practices and get the most of out of their treatments,” says McGowan, “In my work as Medical Director of a large HIV/AIDS Center for Excellence, I wear many hats: administrator, researcher, educator/professor, grant writer, and clinician. The most important to me is to be the best clinician I can. It informs everything else I do. How could I conduct research without knowing what questions have to be asked to address the problems my patients are facing? How could I write grants unless I know where the gaps in care exist? How can I teach if I don’t know what needs to be done to provide proper care?”
When it comes to motivating his patients to adhere to their treatment regimens, McGowan uses a kitchen sink approach. Different things motivate different people. The basis is always education. Says McGowan, “No one should ever be expected to do anything, especially take medication into their body, unless they know why they are doing it and what the expected benefits and risks will be. This is especially important with our modern therapies as we are starting treatment, hopefully, well before symptoms of disease would likely be felt. Beyond that we use a multidisciplinary team of nurses, social workers, health educators, peer navigators/educators, and pharmacists to provide support. Each patient has a treatment plan that will include education,transportation support, referrals for mental health, substance use treatment, and peer support as needed. We work with pharmacies to supply home delivery, pre-packaging, electronic reminders, pill boxes, etc. Peers make daily calls to remind patients to take their medications. Our collective focus is to keep our patients engaged in care and virologically suppressed in order to improve their health outcomes and reduce transmission to others.”
McGowan describes what makes his practice successful. “We start by conducting an in-depth psycho-social assessment at least twice annually and developing an individualized care plan focused on identifying and addressing barriers to treatment. Then each member of the care team has an assigned role; the HIV Primary Care Provider will review the entire history and choose the treatment best suited for the individual; the RN Case Manager will help with education and act as the front line for tolerability and medication access issues; the Social Worker will address issues around insurance, transportation, mental health, substance use, and housing; the Health Educator will address social supports, motivation and set up peer support and education; the Pharmacist will provide uninterrupted access to treatment and the tools and reminders needed to be successful. We work with our community partners collaboratively and not in silos. There are no shortcuts, but the goals are achievable. These efforts are really most needed by perhaps 10 to 15 percent of patients, but without them we will never be able to get ahead of this epidemic.”
“I think we are all faced with decisions every day. The choices we make open up new opportunities. My life was shaped by my upbringing,” recalls McGowan, “As a kid growing up in the South Bronx in the 1960s and 70s, a time of great change and turmoil in that community, my life could have taken dramatically different turns. I benefited greatly from the strength of my family and parents who had my sister and me focus on education and commitment. I am the first doctor in our family; there were no role models.” Looking ahead, McGowan hopes to be able to continue taking care of patients with HIV for the rest of his career. He hopes to be around when the cure comes so that he can see his patients’ faces when they get that good news. In the meantime, New York is working on ending the AIDS epidemic, which means getting the rate of new diagnoses below 750 cases per year by 2020. McGowan hopes to contribute to that effort on Long Island, which has the highest rates of HIV infection in the state outside of New York City. When asked how he envisions the future of HIV care will be, McGowan says, “It has been a real rollercoaster up till now, so predictions must be made very carefully. I would hope that we will be close to a cure in ten years. It is a great motivator for patients to stay focused on treatment adherence. Evolution of treatment is getting more simplified, so long-acting injectable forms of medication will be likely. This will simplify treatment and bypass many adherence barriers that can challenge patients, especially as treatment fatigue sets in.”
Outside of his professional life, McGowan loves to travel. He loves learning and experiencing other cultures. The history of other peoples and the things we share in common help to open up his mind to ways of doing things and responses to events that had been outside his frame of reference. “Our ways are not the only ways, or necessarily the best ways. There is always room to learn.”
McGowan currently serves on AAHIVM’s National Board of Directors as the Chair of AAHIVM’s New York/New Jersey Chapter. As for why he is an AAHIVM Member, McGowan says, “For me advocacy from within a community of peers to address common concerns and problems was the main thing that drew me to AAHIVM. Collectively we can recognize issues that impact us broadly and strengthen our voice in being heard to affect changes for the benefit of our patients and our colleagues.”
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