EXPERIENCE: County Public Health Department & Lack of PrEP

[Blueyedsoul]

First let me preface this post/thread by letting everyone know what I do for a living. I am a non-tenured professor at a major school of medicine in Southern California. I make the commute three times a week to lecture on the history of medical sciences to public health students who end up in many of our state, county as well as other non-government health care related industries. IN FULL DISCLOSURE, I AM NOT AN MD! I have a bachelors in history, a masters in business management, non-degree studies in economics and public policy at Cambridge University Graduate Program, and am now completing a secondary masters in history with a medical history emphasis and have plans to begin a PHD program at the same major Southern California school of medicine with what will hopefully be an emphasis on infectious diseases during the twentieth century.

Secondly, I live in an area which encompasses Palm Springs to the East and West Hollywood/Los Angeles to the West (all within 45 minutes). But more specifically, Palm Springs numbers regarding HIV transmissions are often times cited/lumped together or generally discussed in tandem with Riverside and San Bernardino Counties with the Desert Aids Project being the major non-profit advocacy group for both counties. This area has high degree of immigrants (Mexican and Latin American workers). Their is also a significant African American population; both having high rates of HI transmission. The figure that 1/3 of gay men in.the area are poz. I have not looked at current numbers so I can not vouch for current numbers.

Third, I am a 90% top for young twinks, jocks, frat guys etc... but for that 10% bottom of me, I have a slight fetish for drinking some wine, smoking some weed and then inviting a big black or latino cock over to work over my ass resulting in a cummy hole or a gaping rose bud. With all of that being said, I get tested every three months by the county where results with papers are provided. These results I use to prove my status which the regular non- bugchasing neg tops seem to appreciate. Here's how my Friday morning went....

I get this automated call from the county public health department this morning stating that my last full blood panel back in MAY had not truly validated due to a laboratory "quality control" issue. I needed to call immediately and make an immediate appointment. So, I did! An hour later my blood is drawn and I am chatting with the registered nurse. Now mind you, I have not told the nurse my profession. During this procedure I decide to inquire about the counties PrEP availability. She stopped and look-ed up asking, "What really is that?" As I laid out the case/facts for PrEP, she basically admitted that many of the professionals including herself had little to NO knowledge of the regiment as she continued to literally negate the fact that Truvada had been FDA approved! That's when I disclosed what I did for a living. She then snapped out of the "he's an ignorant uninformed citizen mode" and began to not make explain that the county decided to "opt out" of these preventative measures which included PEP do to COST! This amazed me do to the high degree of infections and significant rise of syphilis within both the African American and Latino communities. I left shaking my head at the lack of education. In fact at one point she admitted to having one class of continuing education on the subject.

I hate to be somewhat political however wasn't this supposed to be a non-issue (theoretically) as the Obama Administration pushed for it's signature legislation (The Affordable Healthcare Act)? What about PEP? Does this make anyone somewhat concerned or downright skeptical of the health care act itself? And then again, maybe it's me and I am not really expressing myself concisely... Thoughts?

[bearbandit]

I hate to be somewhat political however wasn't this supposed to be a non-issue (theoretically) as the Obama Administration pushed for it's signature legislation (The Affordable Healthcare Act)? What about PEP? Does this make anyone somewhat concerned or downright skeptical of the health care act itself? And then again, maybe it's me and I am not really expressing myself concisely... Thoughts?

Looking in from outside, I'd guess that this is nothing to do with politics and everything to do with the fact that most medical staff are run off their feet just doing their job as it stood when they did their first day. I spent three weeks in hospital in July of last year, nearly dying because of an obscure reaction to tenofovir. Once I'd got my mind back (one of the symptoms was essentially a type of dementia) I ended up running what amounted to in-service training with any medical staff who came into my room. Their knowledge was frozen in time. Even the ward sister, when I told her that the largest group of people being diagnosed in the UK today remarked that she didn't think that many women would attracted to druggies... No, dear, we're talking middle aged women who've been through the menopause and have tossed barrier contraception out the window because they don't need it any more. The UK's harm reduction policy has led to an HIV+ rate of about 1% amongst injecting users. No-one but my consultant and his registrar seemed to have any HIV knowledge that was less than five years old, yet I was seeing nursing staff pulling double shifts or split shifts with no time allowed to even glance at a medical journal...

[Blueyedsoul]

Bear: As always thanks for your insights. Regardless of the nature of the cause - political or just work stagnancy/complacency - I was astonished with the lack of knowledge not just among some health professionals but the general public as well. Since PrEP is now approved in the good ol' U.S. of A., I would like to think that demand would be on the rise and consequently the learning curve for professionals would be bolstered. Wishful thinking I guess.

[bearbandit]

Wishful thinking indeed: once the people of the UK were remarkably well, if sensationally - I'll never look at a tombstone or an iceberg in quite the same way again - informed with a leaflet campaign hitting every doorstep in the country and a freephone helpline to back up that campaign (I worked on that helpline and there'd be up to thirty of us on a shift at a time). Now I get 30 year olds on Grindr (the only hookup app/site where I don't list my HIV status) asking me "what's HIV?" In the UK HIV is currently being devolved from specialists to GPs who simply don't have the knowledge, training or right attitude to do the work.

[Blueyedsoul]

DO you think that's the devolving from ID Specialist's to GP's is a direct result of the government controlled healthcare system? A cost cutting measure? Or is it that the system has slowly forced physicians to not bother with an ID specialty?

[bearbandit]

I think it's a result of a movement away from holistic heathcare, where the department caring for the main presenting illness co-ordinated care for co-morbidities to the concept of "centres of excellence" which result in my having to attend three different hospitals for different aspects of the same illness. The shift towards all but HIV drugs being issued by the GP happened as a money juggling exercise: when we in the UK were still thinking in terms of aids rather than advanced HIV disease, GP's became responsible for the prescription of all non-acute treatments. Even though I got my aids diagnosis through persistent herpes, it was suddenly my GP's responsibility to prescribe for it in order to protect the HIV clinic's funding. So I'd say definitely a cost-cutting or budget managing exercise.

While private healthcare is available in the UK, few can afford it, especially when having to pay the drug companies' inflated prices for drugs. Yes, there's private insurance, but the exclusions are legion. Strictly speaking, I suppose, the UK government is the main insurer for healthcare as healthcare funding is supposed to come from "national insurance" which also pays for the benefits system.

[wood]

During this procedure I decide to inquire about the counties PrEP availability. She stopped and look-ed up asking, "What really is that?" As I laid out the case/facts for PrEP, she basically admitted that many of the professionals including herself had little to NO knowledge of the regiment as she continued to literally negate the fact that Truvada had been FDA approved! That's when I disclosed what I did for a living. She then snapped out of the "he's an ignorant uninformed citizen mode" and began to not make explain that the county decided to "opt out" of these preventative measures which included PEP do to COST! This amazed me do to the high degree of infections and significant rise of syphilis within both the African American and Latino communities. I left shaking my head at the lack of education. In fact at one point she admitted to having one class of continuing education on the subject.

I'm not really surprised for a number of reasons.

1) most clinics, both private and publicly funded have very thin budgets they work with. They often don't have access to the newest tools.

2) Most clinics focus is based around first preventing any exposure, and then testing and then treating exposures. They also have to work within accepted models in most cases, So that means saying use a condom everytime, have less partners, get tested often, etc. PrEP while FDA approved is still very new.

3) Many still don't like the idea of PrEP. I have seen this from multiple different people who work in public heath in different ways. The biggest obstacle seems to be convincing doctors and public heath professionals that people are not looking at PrEP as a free for all for crazy sex. (look in the PrEP forum at the article I posted) Luckily I have a very open doctor I can talk too, but in my opinion some are not even giving PrEP as an option because they want people to follow the old methadology of condoms/fewer partners/abstinence. That methadology isnt bad but, it doesnt work for everyone, and I hope we see a shift to more doctors advocating PrEP.