May 2018

Matthew Spinelli, MD

May 2018

The last book Dr. Matthew Spinelli read, In the Light of What we Know, spans multiple countries, explores relationships between geopolitics, science, and mathematics, and details the various ways individuals define home and justify motives for the treatment of our family and companions. In conversation with Spinelli, it’s easy to see how the myriad themes blending together in this novel would inspire admiration in someone who crossed international and intellectual boundaries pursuing his interest in the most politically, socially, biologically challenging disease in modern history.

“I first got interested in HIV when learning about ACT UP in school – I had a fantastic teacher who taught the history of it so well, and I was really excited by the activism potential, the way it changed the landscape of drug development. The social aspects of HIV really drove my interest.”

Further cementing this investment, Dr. Spinelli volunteered in college at an organization called Aid for AIDS, focused on medication recycling.

Sure of his interest in the disease but unsure of the direction he wanted to take (he focused his studies on humanities in college, majoring in Italian Literature), during his senior year Spinelli applied for a grant to do research in Lima, Peru. Receiving the award allowed him to work with a professor of public health in the region exploring the physical and social needs of patients, which helped give him the nudge he needed to attend medical school, enrolling the following autumn. That summer before starting medical school he worked in a virology lab, further driving and expanding his interest in HIV, this time in the basic mechanisms of the virus.

These experiences aligned to bring Spinelli to where he is today – a Fellow in the Division of HIV, Infectious Disease, and Global Medicine. His primary research home is Bridge HIV at the San Francisco Department of Public Health, the program known for its focus on getting to zero in SF (zero new infections, zero AIDS-related deaths, and zero stigma). A site leader in prevention research and the implementation of clinical trials focused on eradicating the virus in our city, it seems a perfect fit.

Entering his 3rd year of fellowship while also working on a master’s degree in clinical research here at UCSF, his role has shifted dramatically from his first year in the training program.

“The first year of fellowship is full-time clinical – the fellows are the face of the consult service across all UCSF hospitals – and we get paged a LOT. I was handling four to eight consults a day. The good part is that most of the consults are HIV related, especially at the General – and that’s what I came here for.”

The second and third year are largely research focused. With clinic one half day a week, the rest of his time is dedicated to exploring some of the most pressing challenges in the field – for Spinelli that’s implementation science. His work focuses on pre-exposure prophylaxis (PrEP).

“Generally people are pretty poor at estimating their own risk for HIV,” explains Spinelli. Given this, getting the most people on PrEP as possible seems an appropriate goal.

“We’re blessed that PrEP is becoming more widely available in general. We’ve seen great uptake in SF – if you randomly ask people in high-burden neighborhoods like the Castro, you get about 40% saying they’re using it. Of course, this population tends to be a more white, more upper middle class, and engaged in care.”

At this point, healthcare providers are still seeing a lot of diagnoses in African Americans, and increasingly in people who inject drugs. Another concern is the how poor the maintenance on PrEP seems to be – even in settings where cost or access is not an issue, only about a third of clients are staying on the drug for a median of about six months. There can be a variety of reasons for this – some people may no longer think they are at risk – something further exacerbated by PrEP use or its discontinuation being a symbol of intimacy and trust among partners. Other clients may switch insurance companies, causing a break in PrEP coverage; others still may simply experience ‘medication fatigue,’ and not want to have to take a daily pill.

Given this, “how do you deliver care as efficiently as possible to the most number of people?” Spinelli asks. “How do we roll out PrEP in more diverse populations – perhaps in spaces that are not HIV-clinic specific, which can deter those who still feel an immense stigma in getting tested or getting treatment?”

Reminiscent of his interest in HIV being motivated by its interdisciplinary nature, Spinelli says that one way to achieve new models of care is by collaborating with other academic fields.

“We have engaged patients who are motivated to be engaged – but now we have to reach the patients who have multiple barriers to care – housing instability, people who inject drugs – how can we be flexible in our approach to care? Differentiated models of care are the way forward – and using people who are specialized to deliver care outside of four clinic walls,” he emphasizes.

Many insights can be gleaned from behavioral economics in particular, Spinelli explains – like what incentivizes people’s behavior and what innovations best get diffused to different populations. There is already evidence of successfully shifting traditional medical care models to meet patients where they’re at.

Matt Spinelli, MD

“Framing PrEP access and uptake as a sexual health promotion model, instead of a ‘risk’ model [historically the terminology and framing used in many primary care settings], which has more pushback, has been helpful – people don’t like to be told they’re at risk for something for various personal reasons.”

For persons who face stigma, lack support, and are uncertain of how they would manage an HIV diagnosis, offering testing and PrEP counseling in a primary care setting can be very helpful. It offers a more comprehensive care model, allowing patients to get vaccines and receive screenings for other diseases, reducing the emphasis on HIV and thereby some of the uncertainty or fear.

Other implementation models are using pharmacies as sites for PrEP engagement and delivery – some preliminary data shows that certain populations may prefer that. However, stresses Spinelli, “that model doesn’t offer the same opportunities as primary care in terms of speaking to patients about their overall needs and getting the rapid HIV test needed to get started on PrEP.” Given that, a hybrid model allowing patients to receive a rapid HIV test at a pharmacy site (with counselors on staff), is a reasonable possibility, he notes.

New ways of administering PrEP, not just its initiation, is another cornerstone of Spinelli’s goals. “Injectables, implants, intermittent PrEP – all these are on the horizon. Increasing the modes of drug delivery also makes it more present in people’s general consciousness,” he says. “It just becomes something a lot of people to do stay healthy.” Wider accessibility leads to greater acceptance, reducing PrEP stigma and encouraging its use among vulnerable populations as well.

This insight – and Spinelli’s research and clinical chops – were honed on Ward 86, where he had some of the most rewarding moments in his career thus far by using the interdisciplinary approach he champions.

“I’ve been lucky to have really transformative experiences with patients. Some that haven’t had suppressed viral loads in years, by working with them holistically – with social workers and counselors to figure out confounding factors prohibiting a suppression – to see that VL suppressed for the first time in 4-5 years is really great.”

After spending so much time in the halls of UCSF’s HIV operational and clinical hubs, Spinelli feels right at home – and having arrived in 2013 to complete his residency, he’s officially no longer a newcomer to the Bay Area. Originally from the New Jersey/New York area, he spent nearly a decade in Manhattan, attending Columbia University as an undergraduate before moving across the island to make a new home at Mt. Sinai for medical school. With HIV securely in his line of focus, San Francisco and UCSF were the natural next step.

Living here has been pretty wonderful, he admits. In his minimal downtime, Spinelli likes to dive into modern fiction, as we’ve already seen – in a nod to his early research experiences, Latin American literature is a favorite, Roberto Bolaño in particular – and explore all the Bay Area has to offer. “I love the hiking and biking, the weather, how nice the people are – and the food and access to ingredients, which is a lot better than the East Coast.” A nod to his interest in cooking, he and his wife, who works in international education, have a cat named Zucca – the Italian word for squash.

“Not that I want to body shame my cat, but Zucca is a little heavy,” he chuckles. With such intense and dedicated focus on the health of humans in the Bay Area, he can easily be forgiven for that.