In September 2013, the Affordable Care Act puts HIV-prevention money on the table but municipal health departments must apply for funds with a plan in mind.
However funded, will prevention programs going forward reflect the fast-changing prevention-treatment continuum? Traditionally, programs by municipal health department programs have separated prevention based on condom use or abstinence and treatment based on adherence to combination therapies.
Now, more than ever, the lines between prevention and treatment are blurred.
Treatment-based options that prevent infection, like PrEP ( pre-exposure prophylactic ) and PEP ( post-exposure prophylactic ), present new opportunities to integrate prevention and treatment models.
Veteran HIV advocates in Chicago and NYC think PEP, as a medical intervention, has a major role to play especially within gay male and bi communities in which the HIV infection has risen by 12 percent, according to the Centers for Disease Control ( CDC ). Gay men are only about 2 percent of the U.S. population, but account for 63 percent of total infections in recent years. Most new infections are young gay men, and over half are Black gay men 13-24 years old.
The CDC says if current trends continue 50 percent of Black men who have sex with men and turned 18 in 2009 will be HIV+ by age 35. Fifty-four percent of all men who have sex with men will be HIV-positive.
In use for about 20 years, PEP can prove to be a significant factor in reducing new infections but only if hospitals and municipal health departments forge ahead to educate about its use and actually offer the treatment. If prescribed within 72 hours and taken for 28 days, PEP is about 80 percent effective in preventing HIV infection.
Awareness is the key.
A 2011 study published in the journal Sexually Transmitted Infections found that just 201, or 36 percent, of 554 men who were interviewed in two NYC bathhouses were aware of PEP or PrEP Besides gay men needing to know about these interventions, hospitals could do a better job too.
The latest round of media attention around PEP began July 17, when members of ACT UP/NYC protested outside of Mt. Sinai Medical Center after when on July 5 a gay man had who had unsafe sex visited the ER and had difficulty acquiring PEP.
At the time, the activists pointed out a wider problem regarding PrEP/PEP awareness. They had identified six examples of PEP refusal, dating from 2009 with four of them occurring in late 2012 or 2013. "When I have six different incidents at six different hospitals over the last four years, something is wrong," Jim Eigo told Gay City News.
"There is variable penetration in ERs regarding their understanding and use of PEP. Not every hospital has a program and there is always room for improvement," said Demetre Daskalakis, MD, a Gay Men's Health Crisis board member who also heads HIV/AIDS services at NYC's Mount Sinai Hospital.
It's not a stretch for hospitals to offer PEP.
"ERs are used to offering PEP. Remember they had occupational programs long before PEP came into use for recent sexual contact or other risky behaviors," Daskalakis pointed out. CDC currently recommends use of Truvada and Isentress.
Daskalakis said, "The key is to offer PEP it quickly, without judgment, and with swift follow-up to assess compliance, and to set the stage for other services the person may need."
PEP is not recommended as a repeat strategy for preventing infection. Daskalakis said, "Repeated requests for PEP may represent an opportunity to talk about PrEP, a way for the individual to prevent infection" going into sexual activity rather than hoping to prevent infection afterward.
All of these pre- and post-interventions sound good on paper but are worthless if people don't know about them.
A random online search of "PEP HIV Chicago" did not produce a single reference to PEP or PrEP, other than the AIDS Foundation of Chicago.
One individual asked an online medical website, "I live in Chicago. Where can I receive the PEP treatment for my possible exposure to HIV two days ago via unprotected sex?"
The online physician replied, "PEP can be prescribed by your primary care physician or general practitioner. You may also contact a hospital attached to a medical school for the prescription of PEP or an urgent care clinic. AIDS Foundation of Chicago also can be contacted."
The next online question was, "Which specific teaching hospitals in the Chicago area offer the PEP treatment?"
The reply: "Chicago Medical School should be offering PEP after assessing the risk in the individuals. Most of the medical teaching facilities do this now."
Questioner's follow up to reply: "I agree CMS should be, but is it? You don't have to answer this in a nanosecond but I want to know which hospital does, not which hospital might or should. That is, please give me a definitive answer."
Final online physician answer: "I am sorry, I do not have a definitive answer. I am opting out of the question, which will open the question for the other experts. Some expert would pick this up to give you a very definitive center. Though I feel, best would be your primary care physician or urgent care clinic."
Final reply from original questioner: "Thank you. As I do not have health insurance and therefore a primary care physician, I don't want to waste time trying to figure out where I can go. I appreciate your input, but I still do not know where I can receive the PEP treatment in Chicago—and that is my question."
By now, the 72-hour window of opportunity for PEP to be effective has expired.
Jill Dispenza—of the Illinois HIV/AIDS/STD Hotline and HIV Testing & Prevention, also affiliated with Center on Halsted—said the service gets "very few" calls about PEP.
Incoming questions are "usually about HIV testing, transmission, risk, medications, sexual assault," she said. Sometimes callers will share "I just found out I'm HIV-positive and want to protect my partners," Dispenza points out. "Then the health educator asks if the caller knows about PEP, if they think the caller would benefit from learning about it," she said.
Right now, Chicago hotline track calls according to a caller's original reason for making contact.
"Our database doesn't allow us to track more than one presenting concern," Dispenza notes. That means unless a caller makes PEP the reason for a call that issue is not tracked. "Still, health educators do inform callers about PEP if at all relevant to the nature of the call," she said. Education by hotline staff also takes place "during the vast majority of our testing sessions, while doing outreach, during individual learning sessions we also discuss PrEP," Dispenza said.
In Chicago, long-ime health advocate Jim Pickett—director of advocacy for the AIDS Foundation of Chicago—said, "PEP has been around a long time. We need to make better use of it as a way to prevent infections. Awareness is the key." He sees both PEP and PrEP as "a natural continuum."
"PEP and the doors it opens to talk about PrEP make it imperative that HIV activists advocates, ER doctors and staff embrace this intervention," he said. Since once infected individuals will eventually daily doses of HIV medicines making any successful PEP or PrEP intervention cost effective.
As the AIDS silo comes down while the Affordable Healthcare Act rises, incorporating blended prevention and treatment interventions is paramount to new reducing infections.
In traditional style, the ACT UP/NYC group has already started the process with the formation of PHAG, Prevention of HIV Action Group, completed with slogans:
—"All You Do Is Give Us Rubbers. We Want Data"
—"POZitively Fraudulent, Absolutely NEGligent" ( illustrating lack of data around PEP effectiveness )
—Referring to NYC Mayor Michael Bloomberg's health promotion efforts:
"He Took Our Sodas, Took Our Smokes, But Left HIV for the Queer Folks"
—On the slow response to PEP as an intervention:
"DOH Get A Clue! PEP 4 All, Not Just 4 U!"
