Transcript for PrEP Module
Text:His Health.
Grow Strong Together.
Module 2. PrEP (Pre-Exposure Prophylaxi).
Theo Hodge, Jr. MD. Capital Medical Associates. Washington, D.C.
David Malebranche, MD, MPH. Cobb County Adult Detention Center. Marietta, GA.
1 in 2 Black MSM and 1 in 4 Latino MSM will be diagnose with HIV within their lifetime.
Young Black MSM account for MORE THAN HALF of new infections among young MSM.
... more than any other subgroup by race/ethnicity, age and sex.
"When new infections among young black gay men increase by nearly 50% in [00:00:30] 3 years we need to do more to show them that their lives matter." President Barack Obama.
Michael:Damn. I am not looking forward to this. Gonorrhea was no joke. So, next up the HIV testing vet. And on date night no less. [00:01:00] Jonathan calls it, "Pay to Play". Look, I'm no angel but I'm careful. Shit. Derek was careful and now him and three other guys came back positive. That's crazy. And Derek's losing it. He keeps talking about his uncle the "Skeleton Under the Sheets," white crap coming out of his mouth, sitting in his own shit because nobody wants to touch him. Talk [00:01:30] about God's wrath. Thank God that was it. I can't help but think my number's up sooner or later. And there's onto living on drugs for the rest of my life. Gotta enjoy life while you can. So with that being said, turn-up time, turn-up, turn-up, dab, dab, turn-up, turn-up, go on up.
Speaker 3:[00:02:00] Wow.
David:Right.
Speaker 3:David it's 2016. And with all the advances we have and treatment and even prevention and the CDC is still saying that one out of two black MSM are going to be diagnosed positive in their lifetime? I mean, as a clinician, as a black gay man myself, even as a human being I'm appalled.
David:Right.
Speaker 3:[00:02:30] This video blog, Michael and his friend Derek are going to be part of that statistic.
David:Yeah, watching it my heart goes out to him because you can hear in his voice and kind of way he's telling the story exactly what he's fearful of. He's talking about that person that he knew who had an uncle who back in the day when HIV didn't have any treatment he's under the sheet, a skeleton, so on and so forth, so that fear is always there, but then he's still going to kind of turn-up and do what he needs [00:03:00] to do. So, it kind of lets us know what we need to be doing as providers, as clinicians and members of the population to kind of help folks out.
Speaker 3:Absolutely. There is no greater urgency than now to address HIV in that particular population. And we as primary health care providers actually have a unique position there, particularly in facilitating HIV prevention.
David:Yeah.
Speaker 3:And now with the event of PrEP we really have [00:03:30] an arsenal that can help turn the tide.
David:Yeah, and I think what's interesting about it, a lot of time as providers we put the blame on the victim, so on our patients, so like, "You need to do this. You need to not have many sexual partners. You need to use condoms every single time," even though we ourselves as providers may not use condoms every single time. And so, I think the context that is coming in right now in 2016 this should be a shared responsibility. We are the providers, we have the tools like you're saying, which kind of brings us to what we're doing [00:04:00] in this module right now.
"And the goal of His Health is to increase the capacity, quality and effectiveness of health care providers to screen, diagnose, link and retain Black MSM in HIV clinical care."
Now for this module we're going to be talking about PrEP, so why don't you start us off and tell us what we're going to be talking about.
Speaker 3:Well, and you know in this module we are going to be looking at the HIV epidemic, specifically in men who have sex with men. And then we're going to examine the HIV prevention toolbox. We're going to open that toolbox and look at specific [00:04:30] tools. Specifically pharmacological intervention that is particularly as noted for treatment as prevention. And we are really going to focus on PrEP.
David:And PrEP stands for Pre-Exposure Prophylaxis correct?
Speaker 3:That would be correct.
David:Okay.
Speaker 3:And finally at the end of this module, hopefully our learners will have number one understood HIV prevention challenges and opportunities for Black men who have sex with men or MSM. Number two adopt CDC recommendations for testing. [00:05:00] Three incorporate CDC recommended prevention strategies as part of patient-care for both HIV and HIV positive Black MSM. And finally to explain PrEP treatment for HIV-negative Black MSM patients.
So let's talk about some definitions. We just mentioned Pre-Exposure Prophylaxis, that's taking a medication to actually prevent the acquisition of HIV. And then TasP, which is Treatment as Prevention, that is HIV transmission prevention [00:05:30] method that uses antiretroviral therapy and viral suppresion to prevent acquisition of HIV.
David:Right.
Speaker 3:And Black, you know people are always asking me about that, that is men of African descent, American and all others. And then finally MSM, and that is men that are sexually active with other men.
David:Yeah, we were actually talking about that in a previous module and just talking a little bit about how that term has been controversial because it doesn't really mean an identity but for providers it's good to kind of include [00:06:00] the behavioral things we talk about.
Speaker 3:Exactly. It kind of helps us organize in our own thoughts and how we approach patients.
David:Absolutely. So, next you're going to be telling us a little bit about the HIV epidemic?
Speaker 3:Yeah, when we look specifically at adolescents and young adults ... and that would include people 13 to 24, and you look specifically at the transmission risk groups in that, it is men who have sex with men who have actually had an increase in both prevalence and incidence of HIV. In 2007, [00:06:30] they were at 67% and in 2010, they had gone up to 76%.
David:Right.
Speaker 3:And notably at the same time heterosexual population dropped from 25 to 18%.
David:Was that both men and women?
Speaker 3:That's both men and women.
David:Gotcha.
Speaker 3:And then when you drill then and look specifically at Black MSM among all MSMs just looking at MSM it is Black MSM that had an increase. They went from slightly over, around 3,000 to over [00:07:00] 4,000 from 2007 to 2010.
Speaker 1:I can breathe again. Shit, that was close. I never, ever, ever want to go through that again. My come to Jesus moment. [00:00:30] Look, I might be getting away with more than most, but I always use a condom, except when I'm with a Jonathan, after two cocktails. Or Frank. Or that one teen and I at Club Liberty. Man, that was a crazy night. So, with that being said, tonight, two drink limit. Focus on Jonathan, and oral only. For now. [00:01:00] Derek coming back positive made it real. Meds or no meds, his life is changed forever. To hell with that.
Speaker 2:When you hear what he was just saying, what do you think about? He was talking about a lot of stuff over there.
Speaker 3:He was talking about a lot of stuff. And it's the usual thing. I remember being his age, [00:01:30] and getting my HIV negative test. I'm like, "Oh, Lord Jesus. I'm negative." And then you say all this stuff about, "Mm-hmm (affirmative). I'm gonna be good, I'm gonna be good." And then in real life, challenges and obstacles prevent you from having a halo over your head. So, I really think that is where we as healthcare providers actually have to assist our patients. To share responsibility.
Speaker 2:Yeah, I think it's interesting because what he was saying [00:02:00] is almost like a disconnect. He was like, "Well, I use condoms most of the time." And then he was like, "Oh, except for that time here. And except for that time there. And except for that time there." And so, even like what you're saying, the shared responsibility as providers, sometimes our patients may tell us intentionally or not intentionally, that they're being somewhat safer. I think there's sometimes a context like when they come into an office someones going to say to you, "Oh, I use condoms all the time," thinking, "Oh my God, I don't want this physician or physician assistant or nurse practitioner to judge me." Or they may just forget. [00:02:30] Whether he forgets or not is almost irrelevant in this case, but I think what it brings upon us is that we have a shared responsibility to work with them as far as their HIV prevention techniques, regardless of what they tell us, may be reflective of the truth or not.
Historically, we've always been talking about behavior. The ABC's, abstinence, behavior modification, lowering your partners, and condoms. But the dynamic has changed recently, and now it's 2016, so what can you tell us about what's going on now in the HIV [00:03:00] prevention world and what tools we have at our disposal.
Speaker 3:Well, as we open our HIV prevention toolbox, what you find is that we have emerging biomedical strategies to address HIV, which is fantastic, because as you mentioned, the behavioral models that we used in the past, condoms, condoms, condoms, that hasn't worked so well. So, with the advent of PrEP, we now have a very strong biomedical intervention that we use. As [00:03:30] we open our toolbox, we now have what we would term, or the concept of combination prevention therapy. Instead of just using behavioral, which clearly hasn't worked as well, we use a combination of things that when used together, actually have greater impact than just a single behavior model.
As you open the toolbox, you see testing, and testing is how any strategy begins. One must know their status before we even think [00:04:00] about using any other prevention strategy. Then we have structural, which looks at the mandate with Obama having insurance, so that people can actually access healthcare. That's an example of a structural prevention strategy. Behavioral, we talked about condoms, limiting your sex partners, those are all behavioral. Then biomedical, which we'll drill down on, and we'll talk about PrEP.
Speaker 2:[00:04:30] What can you tell us a little bit about testing? Is there official recommendations that we have at our disposal?
Speaker 3:As I said, testing begins everything. In 2006 the CDC said, "Hey, healthcare providers, everyone [00:05:00] between the ages of 13 and 64 should be tested, regardless of risk," and that's a huge issue, because when you talk to people, there are so many people who don't feel like they're at risk, and with this guideline, you caught all those people who didn't think they were at risk and you actually found out, "Okay, you are actually positive." Rather than waiting until they became ill to find that out.
That was the guideline in 2006. Everyone between 13 and 64 had to be tested at least once, without regard to risk. Any further [00:05:30] testing would be based on risk. This is an opt out that was suggested, so rather than having a consent, because before you had to sit down, talk to people, get them to sign a consent, no. In this case, it's opt out. So, I say to you, "Hey David, I'm taking your HIV test." Unless you say, "Oh, no, no, no, no, no you're not." Then that test is taken.
Speaker 2:That's part if it, yeah.
Speaker 3:That's all part of it, so that was very important when that came out. Specifically, in terms of testing when it comes to men who have [00:06:00] sex with men, they should test at least once a year, and based on their risk, certainly in my practice, with my patients, three to four times a year, at least. And at the same time, I'm doing all the other STI testing. We talk about HIV, but trust me, HIV has a few other things that go along with it.
Speaker 2:Absolutely. I think It is one of those things where you have to do a case by case thing. There's a guideline that says once a year for everyone within that age group, 13 to 65, [00:06:30] or 64, but for those people who are our patients coming in and they may have a little bit more risk, or may have sexual networks where they could be exposing themselves, it's definitely important for providers to follow them along and do that.
Speaker 3:I would most certainly agree.
Speaker 2:Okay.
Speaker 3:This is where we actually look at what is in the HIV prevention toolbox. We've talked about some general categories, with structural and behavioral. This is where we actually look at the specific tools that are in the toolbox. As you can see, this is well [00:07:00] organized in terms of HIV negative and those living with HIV.
Speaker 2:Right.
Speaker 3:Many times, you can use the same tools for both, but as you look down, since we are focusing on PrEP, you will see that for HIV negatives, oral PrEP, oral and injectable. We'll be talking more about oral today.
Speaker 2:So, the biomedical interventions, that's kind of the main change. I think in the past we used to talk about vaccines, microbicides, sometimes providers were talking about [00:07:30] maybe preventing, trying to prevent herpes infections as a way to go into that, because sometimes herpes infections can increase your risk for HIV acquisition, but those really haven't panned out. What can you tell us about both treatment as prevention and PrEP, as far as how successful they've been?
Speaker 3:Let's talk about treatment as prevention. That is looking specifically at the population that is living with HIV. The HPTN 052 Trial, that was a phase three study, two arm study looking at [00:08:00] the impact of delayed antiretroviral therapy versus early antiretroviral therapy and presenting HIV acquisition and serodiscordant couples, and serodiscordant meaning, one patient is positive and the other one is negative.
Everyone entered this study with T cells between 350 and 550, so they were either randomized to start immediately, or wait until their T cells drop below 250. The primary [00:08:30] endpoints were basically viral genetic transmission. Then you did have the clinical events such as pulmonary tuberculosis.
This is what we found out. There was a 96% reduction of sexual transmission of HIV-
Speaker 2:That's huge.
Speaker 3:... in early antiretroviral therapy versus delayed, big, big deal. When you looked even more carefully, there were no HIV transmissions among people who were virologically [00:09:00] suppressed. If they had an undetectable viral load, they didn't pass the virus on.
Speaker 2:Right. What would be your main take home points for HBTN 052?
Speaker 3:The main take home points is if you're HIV positive, you should be on medication, because if your viral is suppressed, the likelihood of passing the virus on, is dramatically reduced. This is a second study, looking again at treatment as prevention. This is the partner study.
Now the partner study was a prospective study [00:09:30] looking at sero-different couples, both heterosexual and men who have sex with men. We're going to focus on men who have sex with men.
Speaker 2:Sure.
Speaker 3:What happened with the men who had sex with men couples, the person that was positive had been on medication for an average of five years, so remember the person that been on medication an average of five years, the couple had known condomless sex, the [00:10:00] month before entering the trial and made it clear they were going to have continued condomless sex. All right, and they had been together an average of, oh, one and a half years, all right. Remember, the other person was negative, and the HIV positive person was on therapy and undetectable, had to have an undetectable viral load, prior to entering the study.
As you can see, the study lasted for ... The average follow-up was about a little over a year, and as [00:10:30] you can see in that bottom number, they had a lot of condomless sex. Lots of it.
Speaker 2:I think that's realistic on a certain point, because from most of the studies that we see, transmission happens within couples, so it's not necessarily these kind of acts where people are going out and having sex with a casual partner, or random person that they don't know from a hookup, which I think is a lot of the misinformation. It's more within these diets and within these couples, correct?
Speaker 3:Exactly. [00:11:00] You know at the end of the study, there were no transmissions. There were absolutely no transmissions. So, I mean, you know, there are critics of the study that will say, "Well, number one, these [00:11:30] people had no transmissions and they had been having sex prior to this, so maybe it was something outside of viral suppression that was in effect, that was causing the HIV negative patient, or I should say partner, to remain negative." That's one criticism.