At a recent doctor's appointment, a young, gay man of color who is HIV-negative spoke candidly about his sexuality and past struggles with addiction. He was hoping to start a conversation about PrEP (pre-exposure prophylaxis), a treatment regimen that works to prevent HIV-negative individuals from becoming infected. He had heard about it from friends and wanted to take the next step of getting a medical opinion on whether PrEP was right for him.
But his doctor immediately became judgmental and dismissive, clearly uncomfortable with the topic and not equipped to have this important discussion with his patient. As a result, the young man left the appointment feeling defeated and discouraged.
PrEP is highly effective in preventing HIV infection. When taken as prescribed, the once-a-day pill adds another layer of protection - in addition to condoms - against HIV. The treatment involves the use of anti-retroviral medication, which is commonly used for HIV treatment. By interfering with HIV's ability to copy itself in the body post-exposure, it prevents the virus from establishing an infection. If taken every day, PrEP has been shown to reduce the risk of HIV infection by more than 90 percent.
Like any new treatment, there may be misconceptions surrounding PrEP - but if we shy away from discussing it, we are doing a disservice to the thousands of New Yorkers who could benefit from it - particularly those who have a disproportionately higher risk of HIV infection, such as transgender women and young men having sex with men (MSM) of color - and we lose a critical tool to fight HIV/AIDS as an epidemic.
Fortunately, the young man who was turned away by his first doctor didn't give up. Instead, he met with a new provider who welcomed a discussion about PrEP, and is now responsibly taking the medication to prevent himself from becoming HIV positive.
Stigma and discrimination from health care providers can be all too common for those seeking HIV prevention and may make them reluctant to have an open discussion about it. While PrEP is not for everyone, everyone should feel comfortable considering it and accessing it. More providers must be not only prepared to have these conversations but able to actively prompt them. Only then will people in marginalized groups -who often lack quality, comprehensive health care - feel comfortable discussing sensitive topics.
When fewer people are HIV-positive, virus transmission will be reduced. By preventing new HIV infections, PrEP not only enables people to live healthier lives, it also prevents hundreds of thousands of dollars spent to treat each individual with HIV. To put this in perspective, it costs an average of $55,000 over five years for one patient to be on PrEP. However, a lifetime of HIV treatment can cost 10 times that amount, between $400,000 and $500,000.
By helping HIV-negative individuals stay that way, PrEP is one of the most important resources to stem the spread of the HIV virus. Governor Andrew Cuomo's Blueprint to End the AIDS Epidemic in New York State (EtE) identifies the usage of PrEP as a key component of achieving the goal of reducing the number of new HIV infections from 3,000 per year to fewer than 750 and ending AIDS as an epidemic in New York by the end of 2020.
In a promising indicator of EtE's success, New York State Medicaid data have shown that PrEP usage is increasing across the state - there has been a more than four-fold increase in PrEP prescriptions between 2014 and 2015, from 303 to 1,330. However, this overall increase in PrEP prescriptions isn't enough to end the epidemic if PrEP isn't reaching the communities who need it most.
Young MSM and transgender individuals have the highest risk for contracting HIV but one of the lowest rates of PrEP uptake. Transgender women have 49 times the odds of having HIV compared to the general population globally. Half of black gay men and a quarter of Latino gay men in the U.S. are projected to be diagnosed with HIV within their lifetime but are far less likely to be taking PrEP than other groups.
Despite these statistics, a 2013 study found that 34 percent of surveyed infectious disease physicians did not feel that PrEP was relevant to their practice. In order to get PrEP in the hands of those who need it the most, more providers need to understand the benefits of PrEP so they will be well-equipped to prescribe it appropriately.
Amida Care - New York's largest Medicaid Special Needs health Plan (SNP) for people living with chronic health conditions such as HIV/AIDS - believes more training is needed to help providers handle the specific needs of transgender patients and communicate more effectively about PrEP to this at-risk population. Since SNPs are specifically designed to engage vulnerable individuals in care and provide integrated social support services, SNPs would also be a great resource to support transgender individuals who are HIV negative in living their authentic lives and remaining HIV negative.
In addition to educating providers, it is critical for the general public to understand the proper usage of PrEP - it does not replace condom use, and safe-sex practices in addition to PrEP are a vital component for remaining healthy.
We have the tools to end the epidemic - but we need to support people who are HIV-negative in staying negative, and PrEP is one of the best ways to help prevent and ultimately eradicate new HIV infections. PrEP users are also more engaged in care and receive more frequent screenings for other STIs, allowing them to take control of their sexual health beyond preventing HIV.
In situations where the cost is a barrier to PrEP usage, NYC community health centers such as Brightpoint Health, BOOM!Health, Callen-Lorde Community Health Center, Community Healthcare Network, Harlem United, and Housing Works assist their clients in finding ways to pay for PrEP. More information about payment assistance is available at the New York State Department of Health website, and a variety of PrEP information resources are available at the New York City Department of Health website.
Everyone should consider using PrEP as a tool to stay healthy and safe. However, it may not be right for everyone - and that's where providers play an important role. It is imperative that providers help educate and empower patients by having open and honest conversations that are both critical for their individual health and the health of our community as a whole.