But the benefits of PrEP can only be reaped if people use it. Currently too few do.

Yesterday was the 32nd year that a AIDS March took place in Seattle. Much of the conversation was around the benefits of PrEP as a preventative drug. With about 40,000 people a year contracting HIV the challenge is huge. At $1,500.00 a month, without insurance, its not a reality for people to maintain a protective schedule. The following article offers some insights into the hopes and challenges.

PBS News Hour – 29 September 2018
“…The CDC estimates that about 1.1 million people in the U.S. should be taking PrEP, including men who have sex with men, sex workers, and transgender women, a population with a highly elevated risk of contracting HIV. But only about 200,000 are actually using it, Redfield said.

Paradoxically, doctors bear part of the blame for that gap.

“There is a large number of people who are not comfortable prescribing PrEP or have not been taught how to prescribe PrEP, whether it be in their residency, fellowship, or post-graduate training,” said Dr. Robert Goldstein, medical director of the transgender health program at Massachusetts General Hospital and an instructor at Harvard Medical School.

“We’re limited by stigma within the medical community and within the LGBT community. We’re limited by lack of provider knowledge. We’re limited by awareness among those at highest risk of HIV infection,” Goldstein said. “And those limitations result in rising rates of new HIV infections in men who have sex with men while we see across the country actually dropping rates of new HIV infections year after year.”

In some cases, the problem of too little PrEP prescribing is due to a lack of training, and in other cases, something else may be at play, suggested Dr. Demetre Daskalakis, the New York Department of Health’s deputy commissioner of disease control.

“We still have to sell this to [clinicians] who are like, ‘Why would I be offering people PrEP, if it’s going to encourage them to have condomless sex?’” he said. “And our answer tends to be, ‘They’re already having condomless sex and this prevents HIV.’”

New York is one of several cities — San Francisco and Washington, D.C., among them — that have moved aggressively to harness the power of the treatment and prevention, working to actively identify people who are HIV-positive but who haven’t yet been tested, or haven’t yet started taking antiretroviral drugs, as well as people who should be using PrEP, but are not.

New York has expanded the remit of its sexual health clinics to help identify these patients and get them into treatment, said Daskalakis, who explained it’s about “snagging” the people most at risk “where they come for service.”

Anyone who is newly diagnosed with HIV is offered antiretroviral drugs immediately. No waiting for a follow-up appointment, which increases the possibility the patient won’t return. And it’s working “with just staggering success,” said Daskalakis.

“What we’re finding is that they get virally suppressed faster,” he said. “It’s sort of the dream, that when you start people on medicines for infections they have on the day of their diagnosis, all of a sudden you see that they’re interested in connecting to care and actually follow through.”

Likewise, people who test negative for HIV but who are deemed at risk of becoming infected are offered a starter pack of PrEP. The efforts led to a sharp upswing in the number of people taking PrEP — and a swift decline in the number of new HIV diagnoses. In 2016, new infections dropped 10 percent overall, and 15 percent among men who have sex with men, Daskalakis said.

The cost of PrEP is steep — $1,500 a month without insurance or assistance from the manufacturer. But New York state has an assistance program that helps with the cost of the medical care PrEP use requires, and there’s a patient assistance program for those who can’t pay for the drug. At the end of the day, Daskalakis said, with a combination of programs, most patients can access PrEP.

“In New York, the answer is yes. But I would be more worried about talking to someone in Mississippi,” he said.

That isn’t an insignificant consideration. The epidemic in the United States is currently being driven, in large part, by infections among African-American and Latino men who have sex with men in several Southern states.

Fauci is a believer in the active style of HIV interventions New York and other cities are employing. “You can’t do business as usual,” he said. “You’ve got to have an aggressive approach.”

But he’s always cognizant that translating the successes of Washington or New York to less urban settings — where access to care is more limited and stigma may be greater — likely won’t be as simple as changing some wording on some brochures.

“Is that going to work in Alabama? In Georgia? In Mississippi and Louisiana? That’s where we’ve got to put the focus on,” Fauci said.

Another challenge that likely won’t be easily overcome relates to the opioid epidemic. The growth in the use of injectable drugs — specifically the sharing of syringes — has driven up HIV and hepatitis C rates in people using illicit substances.

Research shows that needle exchange programs reduce those infections. Separately, a number of cities — San Francisco, Philadelphia, New York, and Seattle, among them— have been exploring opening safe injection sites.

But just as some doctors associate PrEP prescription with enabling unsafe behavior, the notion of sanctioned injection sites and syringe programs draws the ire of people who believe they encourage illegal activity.

In an opinion piece in the New York Times, Deputy Attorney General Rod Rosenstein warned the Department of Justice would take swift action against cities that open such facilities, calling them illegal.

“Americans struggling with addiction need treatment and reduced access to deadly drugs. They do not need a taxpayer-sponsored haven to shoot up,” he wrote.

Public health experts counter that criminalizing drug use hasn’t worked. Officials can’t “punish people into getting well,” said Dr. Sarah Wakeman, medical director of the substance use disorder program at Mass. General.

“At the highest levels of our government, there’s a lot of opposition and antipathy to the idea of harm reduction,” Wakeman said of Rosenstein’s commentary. “And in fact, in that op-ed, it was very clearly stated that these efforts are ‘enabling’ — which I think is one of the many kind of myths around harm reduction.”

“We’ll never get to a place where we can stop the spread of HIV unless we are willing to rethink the way we take care of, and our policy towards people who use drugs in this country,” she said.

Needle exchange programs have some high-profile supporters, including top officials who have had up-close experience with the problem. The CDC’s Redfield has a son who has struggled with opioid addiction; Surgeon General Jerome Adams has a younger brother who has fought addiction for two decades.

“We believe there is clear evidence that needle exchange programs can reduce the risk of transmission of HIV infection,” said Redfield. Adams told STAT last week: “When I see a [needle exchange] program close, what that says to me is that we haven’t done a good enough job communicating to the community why this program is important and the value that it provides.”

The hardest sell yet may be to convince authorities that successfully containing the spread of HIV in the U.S. requires addressing transmission in prisons. Prisons, in theory, “should be easy, because it’s a confined population,” said Fauci. He acknowledged, however, the gap is wide here between theory and reality.

“You’ve just got to get really flexible in what you do and recognize that there is sex going on, there is injection drug use going on. And if you really want to address it, you really have to address it in those settings,” he said. “And that, I know, is going to raise a lot of eyebrows. But it’s got to be done.”

Photo: Taken by M. Barrett Miller at the AIDS Walk, Seattle, 29 September 2018

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“Since 1989, when I returned to the states from Ireland, I have been involved with many people diagnosed with HIV. I have been on various care teams, support groups, panels, marches, fund raising events, as well as starting a non profit dedicated to giving those stricken with HIV a way to participate in society. Nothing has been clearer than the desperate loneliness and isolation many HIV/AIDS sufferers face every day of their lives. Years ago I began bringing HIV+ speakers into my college classroom to educate students on the disease, its effects and ways to avoid behavior that would put a person at risk. It took me quite a while to realize that these speakers were continually sharing stories of loss; loss of friends and family to fear, ignorance, anger and remorse leaving them truly on their own to cope with a malady brought on because ‘they trusted someone.’ These are their stories. Stories full of courage, challenges and hope. I am proud that I have been able to share their journey. . .”

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