Sunday, Feb. 23, 2020 | 2 a.m.
What would you do if you needed a potentially lifesaving medication within 72 hours, but your doctor didn’t know where to get it? When it comes to HIV prevention in Southern Nevada, there’s a gap in education and communication among medical providers, and it’s having a direct effect on the lives of patients.
According to AIDSVu, a project by Emory University’s Rollins School of Public Health, there are nearly 10,000 people living with HIV in Las Vegas. The state’s Division of Public and Behavioral Health reported 507 new infections in Nevada in 2018 alone.
“The epidemic is not over,” says Antioco Carrillo, executive director of Aid for AIDS of Nevada (AFAN). “If you look at the Clark County infection rate, you’ll find an average of 430 to 450 people that are newly diagnosed on a yearly basis. That’s more than one a day. People can still suffer tremendously; we still have people that die.”
For those at high risk of contracting HIV, there’s a drug that has proven successful at reducing infection rates. PrEP, or pre-exposure prophylaxis, is a daily medication that HIV-negative individuals can take to reduce the risk of transmission if they’re exposed to the virus. According to HIV.gov, the pill is 90% effective, even more so when combined with other measures, such as condoms. While most insurance companies cover Truvada and Descovy, the two FDA-approved drugs from Gilead Sciences, there are medication assistance programs like Ready, Set, PrEP that can help with PrEP’s costs.
Similar to PrEP, PEP, or post-exposure prophylaxis, is a 28-day course of HIV medicines that can be taken up to 72 hours after exposure to the HIV virus. The problem is, some health care providers don’t prescribe it.
The Huntridge Family Clinic, a medical provider in Downtown Las Vegas, is conducting a study on 35 patients who sought out and used PEP. Many reported a number of barriers that prevented access to the time-sensitive medication.
“What we identified previously was, people were going to emergency rooms and urgent cares and primary care providers [requesting PEP], and were being told, ‘No, we don’t do that; we don’t know what that is,’ ” says John “Rob” Phoenix, founder of the Huntridge Family Clinic.
Las Vegas Weekly called 11 Valley emergency rooms; seven said they do not provide PEP. One recommended calling the Southern Nevada Health Department,one suggested calling a primary care doctor and four recommended calling a different ER.
“Generally speaking, most patients access at least two, sometimes three or four places before they find us,” Phoenix says. “They’ll go to an urgent care and they’ll be told things like, ‘Well, that’s what you get for having sex like that,’ or ‘You’re going to get infected anyway.’ Those are some of the comments that patients have told us they’ve been told by providers at other agencies.”
Phoenix has been prescribing PEP since 2014, when a patient who had been exposed to HIV requested it. The patient’s primary care provider sent the man to an infectious disease provider, which told him it only helped people who have already been infected. The specialist referred him to a local ER, which referred him to the health department, which then referred him to the Huntridge Clinic. “I’d never [prescribed] PEP before,” Phoenix says. “Now we provide more PEP in Clark County than any other provider.”
The sex talk
Why, in 2020, is lifesaving medication so difficult to obtain? Phoenix says it’s because most medical providers aren’t comfortable talking about sex. “It’s an HIV-related medication,” Phoenix says, “and there’s a whole lot of fear and stigma around HIV. It’s been so pigeonholed for 35-plus years of the epidemic.”
But PrEP and PEP have been approved by the FDA since 2012, and PEP has been used by first responders and medical practitioners in accidental exposure cases since the ’90s.
“If a nurse or doctor got stuck with a needle in a hospital, this is exactly the same thing we would do for them,” Phoenix continues. “What’s different? This is about sex, and we don’t want to ask questions about sex.”
Phoenix says that an estimated 75-80 patients come to Huntridge Clinic requesting PEP each year, many of whom have primary care doctors elsewhere who don’t provide the drug. While most private insurance companies cover PEP, according to aidschicago.org, if a person ends up going to the ER for PEP, it can cost up to $1,000 for the visit. Prior to finding the Huntridge Clinic, one patient received only a week’s dose of PEP at the ER without follow-up instructions on how to obtain the other 21 days of medication.
“We need to work with the schools—nursing schools, medical schools, residency programs—and we need to teach new providers right from the beginning what this is and how easy it is and how important it is,” Phoenix says. The Huntridge Clinic staffs nurse practitioner students from UNLV and elsewhere, “and we make this part of their education,” Phoenix says. He adds that sexual history questions should be just as routine as questions like “Do you smoke?” and “When was your last pap smear?”
“Questions like, ‘What types of partners do you have?’ and, ‘Do you use condoms?’ should be just as common,” Phoenix says. Not asking these sometimes uncomfortable questions means that doctors aren’t getting all the information on a patient’s medical history, which can result in missed diagnoses.
“If primary care providers haven’t seen syphilis in their practice in the last year, it’s because they’re not looking,” Phoenix continues. “We have an epidemic of syphilis in the United States. Nevada is No. 1 in the country right now for syphilis, and it’s a huge risk factor for HIV infection.”
Changing the way the medical community views sex is an uphill battle, Phoenix says. “There’s a study that looked at medical students’ comfort level of taking a sexual health history, and most medical students were uncomfortable,” he says. “When you added questions about LGBTQ issues, that number went down even further.”
By the time students at the Huntridge Clinic have finished their rotation, Phoenix says, those questions are just part of the routine. One student who works in a local hospital found a patient with rectal gonorrhea who had previously been admitted to the hospital three times. “Nobody had ever asked him about sex,” Phoenix says.
Regardless of the type of practice, Phoenix adds that all medical practitioners should gather a patient’s sexual history. “If [you’re] a neurologist, you could be seeing somebody for neurosyphilis because they’re complaining of memory loss and they’re falling. They should be asking questions to protect you,” Phoenix says.
Eradicating the stigma
A lot of the stigma is judgment-based, AFAN’s Carrillo says. Even when it comes to PrEP, many primary care providers don’t prescribe it. “When we start looking at prevention, we want to be able to look at layers,” Carrillo says. PrEP is beneficial for people engaging in high-risk activity, but it’s also a lifesaver for serodiscordant couples, where one partner is HIV-positive and the other is HIV-negative.
The arguments against PrEP are similar to those women have heard for years against birth control—that you can “just do whatever you want and be irresponsible,” Carrillo says. “[But] nobody has ever stopped people from doing whatever they wanted.”
PrEP is still a relatively new drug in the public sphere—approved by the FDA just eight years ago—and societal acceptance has been somewhat slow. “The first year [PrEP] was OK’ed, there was still a lot of controversy. But about a year ago, that started subsiding, and people are not as opposed to it as they once were,” Carrillo says, adding that it’s going to take more momentum to normalize access.
“If you want to be safe as much as you can knowing that once in a while you may be exposed to HIV, take the meds. Work with your health care provider, talk about the side effects,” Carrillo says. “It’s another layer of prevention.”
This story appeared in Las Vegas Weekly.