Barriers: Reasons why vulnerable people stop PrEP

[fskn]

A thread in another forum,

veered off into discussion of why people facing the greatest risk sometimes stop PrEP. I'm starting a new thread here to continue the conversation. Please add your own observations, @hntnhole, @WiChaser, @MrsTatt00, and others.

In surveys, common reasons that young MSM in San Francisco give for stopping PrEP are:

• Losing health insurance

• Believing that their sexual risk has dropped

Correlates that researchers observe are:

• Precarious housing

• Precarious employment

It's hard to be certain, because people may be embarrassed to admit that they have stopped PrEP, and may tell counselors what they think the counselors want to hear.

Negative signals are often more informative than positive ones, but harder to get. For example, a few years after she had started her small business, I told the owner of my local bakery that she should routinely overbake, count what's left at the end of the day, and cheerfully throw it out. The value would be in the data. Even if she could survey all of her late-afternoon customers, she could never know for sure what they would have bought if it had been on the shelf, in front of them.

Insurance changes: Despite Medicaid expansion, generous Affordable Care Act subsidies, and the preventive care mandate, any change in insurance can interrupt PrEP access for months. Without a universal health insurance plan, I don't know how to solve this. For now, the focus ought to be on cheap, convenient bridging, such as giving clinics money to dispense 30-day bottles of Aurobindo's low-cost generic Truvada on the spot.

Reduced risk: Often imaginary, this gets at the sense of invincibility that @hntnhole mentioned. Maybe logging pills taken each day, and sexual activity, and seeing a current risk score would help; some PrEP studies provide apps for this purpose. If sex tracking were integrated into hookup apps like Grindr, people might be more likely to try it. Intermittent or "2-1-1" PrEP seems to be a vital alternative when people believe they no longer need daily PrEP.

Precarious housing: So many health care processes require a fixed address. ACA applications, public benefit recertifications, insurance ID cards, drug rebate coupons (where still necessary), and other bureaucratic nonsense should be reduced to the bare minimum and be made available from mobile Web browsers on cell phones. People who don't want to mail documents, and who can't receive documents in the mail, shouldn't be excluded. Patients should always have the option to pick up PrEP prescriptions near where they are at the moment.

Precarious employment: It's time to decouple all health insurance from employment. It's also time for stupid, backward public and private medical offices to offer evening and weekend drop-in hours. If we want to protect vulnerable people, staffing up is worth the cost. To be really blunt, people with economic resources, political influence, and good health care enjoy fucking vulnerable people. What comfortable middle-class bottom doesn't like taking dick from an edgy thuggish badboy top now and then? (I'm deliberately speaking in stereotypes.) Investing in protecting vulnerable people protects everyone.

The fewer barriers, the more people will use PrEP and the more HIV infections will be prevented. I'd like to see small quantities of Truvada/generics, with easy-to-follow "2-1-1" instructions, handed out without prescription at sex clubs, glory hole places, cruising areas, and gay events/parties. I'm always the first to say that PrEP should be used under medical supervision, but open access might be the only way to reach high-risk people who don't engage with the medical system. (Paradoxically, the problem is worse and more insidious in jurisdictions with universal health insurance. For example, for the first few months of the COVID-19 vaccination campaign in Ontario, Canada, there was no way for undocumented immigrants, immigrants with legal status but still in their first three months of residence, visitors from other Canadian provinces, and homeless people who had lost their health cards, to get vaccinated. No Ontario health card, no vaccine, and fuck you! Every health system needs flexibility.)

Maybe throw a home HIV test in the package, knowing that it's a lousy, second-generation diagnostic that can only tell you your HIV status as of 3–6 months ago. It's cheap, easy, private, and better than nothing!

Of note, the 2021 CDC PrEP guidelines have relaxed safety monitoring. For people under 50 with good initial kidney test results, kidney monitoring is now yearly. Throw in a coupon to visit an outpatient lab (or a chain pharmacy?) for a kidney test, and hope some people use it, but don't let safety monitoring be a blocker! HIV treatment regimens carry a far greater risk of side effects than do HIV prevention regimens.

Edited January 30, 2022 by fskn
Figured out a better way to link the original thread

[hntnhole]

First, fskn, thanks for moving the thread.  Secondly, thanks for the very well informed post.  Clearly you know more than most about these problems.  

To the listed items:  1) lost insurance 2) decreased risk 3&4)  precarious housing and employment:

1.  These are social depravities, with strong, debilitating affects on the underserved in the US.  Unless one happens to be a full-blooded Indigenous Native American (which group has suffered mightily at the hands of the Government), you are either an immigrant or the descendant of one, and almost certainly not Caucasian.  While in some areas of the country it is not accepted, the fact is that non-Caucasians have been treated with little compassion by the Government for 400 years.  This generational  inequity has soaked into the very dirt beneath our feet.  Obviously Government-sponsored health-insurance should follow the individual, not their employer or any other second-party.  The social contract should be between the individual and his/her Government, via the agencies set up to accomplish that important task.  It is a "given" that people favored by the institutions of Government are well-served, or at least better served.  The relationship between the individual and the insurance provider need not depend on extraneous service providers - they are there to provide health care, not be a part of managing who gets insurance and who doesn't.  The problem is surely not with the individual who has lost their insurance, often through no fault of their own.

2.  The issue of risk awareness (i.e. consequences of serious illness vs individual impressions, misinformation) is something the Government can impact via public service announcements (I mean more like commercials for every little tiny worthless thing on tv), professionally written and produced, and run serially on every platform.  HHS would do well to invest (that's exactly what it would be) in such a program, since it would not only present useful, true information, but would also soak into the community-at-large that risk awareness is something that everyone should be cognizant of.  Remember when Elizabeth Birch ran the HRC?  She initiated the "come out, come out wherever you are" campaign, which went a long way towards normalizing gay people.  And when we did come out, family members, neighbors, employers, co-workers realized that we're not the demons as previously thought.  Now, on almost every Netflix series, there are gay characters, and no one gives a hoot.  The same thing can happen with our tax dough, to take the stigma of the unknown "gay" illness down a few pegs.  As we know, misinformation seems to be the order of the day, politically speaking.  The Government can easily fight this battle too. But, without a very large (i.e. Governmental) information campaign, far too many will rely on hearsay (for instance, some of the garbage on <polite cough> certain websites). I think that once people are armed with reliable information, they will recognize what they need to do.  Most people buy X brand of soap flakes because they ae inundated by ads from the soapflakes company.  Why not turn the internet to some useful instrument of disbursing real information?  With everyone's nose buried in their phones these days, it can't help but get reliable messages out.  Without any widely accepted source of reliable, non-judgemental information, the folks who need the information the most won't be able to access it. When that ignorance is allowed to fester, folks may well thing something like "I've been doing this for a long time - no reason to alter my behavior", or along those lines.  In the absence of such an information source, folks wind up thinking whatever they happened to hear over the backyard fence.  Or a trick.  Or any other "special" place.  Ideally, the Government could mesh both a comprehensive media campaign with a health-care campaign; reportedly, they can walk and chew shit at the same time.

3.  This is the most egregious of all.  Some of you won't like this, and may want to skip it.  If there are precarious housing problems for certain segments of our citizenry, then why the fuck is that?  Why is it that some folks have a tough time which mansion they're going to live in that month, and which the next?  Why are the underpasses full of homeless folks?  Some are worthy and some are not?  Hardly.  It's because our Government is dominated by one certain subset of persons, who have traditionally controlled Government for centuries, and overlooked the humanity of others for even longer.  In case anyone missed it, I mean Caucasians. Currently, we see these "Entitled" Powermongers actually changing voting laws in certain States, merely to preserve their own privilege and power.  Their depravity is mind-bending.  What harm does it do the nation to insure that everyone gets decent housing?  A handful of senators* unable to pocket millions for a year or two?  Forced to live in only 2 mansions for a years or two?  Forced to abstain from the Maserati or Ferrari and put up with a Cadillac or Lincoln for a year or two?  Would it be so terrible to share enough of the wealth so that everyone could have decent housing?  The child-tax credit has just expired, and almost certainly will not be renewed until after the primaries, and most likely not at all until after the 2024 election.

I see the listed issues in this post as worthy Government pursuits.  The problems are so large, so diverse, I think only Government can fix them.  Foundations, Human Rights organizations can help, offer expertise, but only the Government can make such a massive undertaking come to pass.  

I use a different place for political commentary, and it can get far more blunt than the above,  If it sounds like I am angry about these un-addressed issues, I'm not.  What I am, is enraged.  Worse, I have managed to devolve into the political arena, where this may not belong.  My apologies.

 

*small case intentional

[fskn]

I share your political anger, @hntnhole. I wish more people would get angry about these issues, because that's how we start to fix them.

I especially like your analogy of the HRC campaign, which helped normalize being gay, in the eyes of the heteros in our lives. I saw a documentary about pioneering GLBT state-level politicians in California, which posited four steps needed to establish rights for any kind of minority group. The first one was simply identifying the people, making them plainly visible to everyone. To me, the HRC campaign and other similar initiatives had that effect.

I also like your point about how gay TV characters are now commonplace. Sadly, the treatment of HIV (often simply confused with AIDS) on TV has not caught up with reality. In this domain, TV amplifies misinformation. 

The only time I've seen PrEP mentioned on a TV show was on Looking. Sure enough, a pair of gay content creators lept right into the trap set for us by heteros and had Patrick stigmatize Brady, who had not only stolen his ex-boyfriend Richie but who dared be open about using PrEP. This petty nonsense validated the false assumption that PrEP users are worthless, dirty sluts — not people who care about themselves and about others enough to do something serious, consistent and effective to interrupt the transmission of HIV.

TV and film producers have started to retain consultants when their programs deal with issues like trauma, suicide or sexual assault. Maybe we need to field medical consultants in Hollywood who can explain the difference between HIV and AIDS, how HIV is actually transmitted, that U=U, and that PrEP is available. One measure of success would be to see straight characters taking PrEP. It seems quite logical, because virtually all straight sex is condom-free (and this is not stigmatized). I've had more than one straight male friend get curious when I mention that a pill can prevent HIV infection. (And of course it works for women and trans people, too.)

Political changes aside, what do you think about medical changes, namely, relaxing the requirements for prescriptions and testing, only for populations who would otherwise never use PrEP?

[BootmanLA]

9 minutes ago, fskn said:

Political changes aside, what do you think about medical changes, namely, relaxing the requirements for prescriptions and testing, only for populations who would otherwise never use PrEP?

For what it's worth: I personally go around and around with this one, unable to settle on a "this path is best" course in either direction.

On the plus side: getting more people onto PrEP has proven to be a good thing, and infection rates in some populations have decreased sharply in recent years. That's great, and it suggests that getting even more people onto PrEP - in other words, reducing the barriers to both going on PrEP in the first place, and staying on it - would be a good thing too.

But on the minus side: we know that in many vulnerable populations, taking medications regularly is an issue. We already see this with HIV *treatment*, where even one pill a day, when freely provided, is something that some populations can't manage. Granted, most of these are both (permanently or intermittently) homeless and (frequently) have some form of mental illness - which are separate issues that require intervention. But not all people who have trouble adhering to a treatment regimen fit those categories; and moreover, some not insignificant portion of the communities we're trying to reach with PrEP ARE in those categories.

And the "tag along" problem that happens in these cases is drug-resistant HIV, which is at present a very small problem, but one which has the potential to become much worse. We have a number of diseases already floating out there which have variants that fail to respond to almost all treatments. The last thing we need is for a PrEP resistant strain of HIV to take hold in a particularly sexually active community.

 Really, there are at least three major groups that are currently "underserved" that have very little overlap. The first would be those I mentioned above - people without steady housing or employment and the mentally ill. The second would be young people on their parents' insurance who don't want the parents to know they're being tested for STI's and getting PrEP. The third is the poor population in states without expanded Medicaid who fall into the gap below qualifying for ACA subsidized insurance. There may be other groups I'm leaving out, and that's not deliberate, but these illustrate the differences we'd need in approaches to solving the issue for each.

For the first group, it's a balancing act for preventing infection vs. preventing drug-resistant strains from developing and spreading. In the long run, the solutions there will likely be long-acting injections for PrEP, ideally ones that can be overlapped (so that you get them in every month for a booster, but if they are 3 weeks late, or miss a month, they're still protected).

For the second group, it probably would require legislation separating dependents from their parents in terms of insurance information access - something unlikely to happen. If a covered dependent over the age of majority were allowed to opt to keep certain information private, from their parents, on insurance records, a young person might feel confident going to a doctor and getting PrEP (or birth control, for that matter). Since the insurer can't charge a copay or anything else for these services, in an ideal world only the patient would actually know what services were received. I'm sure right-wing parents would scream bloody murder, though, and I doubt you could get legislation protecting this information passed.

For the third group, I'm not sure what to do. These are people who presumably wouldn't have a problem getting the tests and taking the medication, but without insurance, there's nobody paying for it. Maybe an expansion of Ryan White funding could fill in the gap in those 13 states, only for PrEP (and again, birth control for that matter), such that this one aspect of health care was actually universal. But that, of course, means more funding, and since it's directed at the states which were obstinate about expanding Medicaid, there might be pushback from states that did and chose to bear that 10% cost themselves. 

[fskn]

I like your enumeration of the three groups, to which I would add injection drug users (IDU).

On-demand/"2-1-1" PrEP, handed out in the community and without prescription, would seem to be better for homeless people than daily PrEP. The 2-month injectable is also promising, but it is not compatible with mobility or with a delay in returning for the next injection.

Is resistant HIV in people who resume PrEP (rather than starting a complete treatment regimen right away) after having stopped PrEP and become infected unknowingly, as big a concern as people make it out to be? Few drugs are approved to prevent HIV (2 2-drug combination pills with 1 drug in common and the other closely related, and 1 new injectable drug) but many drugs (which can be prescribed in many combinations) are available to treat HIV. In a disaster scenario, wouldn't removing all PrEP agents from use in first-line treatment still leave a big arsenal? I'm curious about current thinking among research physicians.

The lack of privacy suffered by young people who remain on their parents' health insurance plans is a terrible barrier to all kinds of important care — mental health, birth control, vaccination, HIV prevention, HIV treatment, etc. (And yet, coverage through age 25 on a parent's plan was one of the first visible ACA provisions. As a privilege for the politically powerful middle class, it could help shield the ACA from repeal. I'm sure this was a careful political calculation.)

Here in California young people over a certain age do have a privacy right in medical records, but this does not (and realistically could not) extend to billing records. An explanation of benefits will be generated even if care is provided at no out-of-pocket cost.

School- and community-based health clinics that can tap sources of funding other than parental insurance are vital.

[hntnhole]

7 hours ago, fskn said:

Here in California young people over a certain age do have a privacy right in medical records, but this does not (and realistically could not) extend to billing records

There is an easy way around this.  Any business of decent size retains a professional CPA service, which assigns numerical codes to all areas of expense that particular company incures. Thus, whether electronic or actual checks written to pay various invoices, the specific accounting code is also entered, which information is for the CPA firm only.  When desired, these codes can be "double-protected", in that the initial numerical code leads only to another one.  The point is to make it as difficult as possible for any outside agency to unearth the actual purpose of the payable.  Plus, there are other ways to compensate the CPA firm, particularly when it's a gay-owned/operated company, and I don't mean fucking them.  As it happens, my partner and I had a weekend place, and twice a year we invited the accountant and his other half to spend some time there.  Purely as friends, of course. 

[hntnhole]

7 hours ago, fskn said:

could help shield the ACA from repeal

But.  There is an even more powerful act which could accomplish that and so much more.  It's called VOTING.  Crucial at the local level, critical at the State level, and of utmost importance at the Federal level.  

[blackrobe]

Reading threads like this makes me so very grateful for the thoughtful, intelligent, and sex-positive men in our community.

[hntnhole]

I couldn't agree more !!! 

Dull guys are good for some things, but intelligence, honesty, integrity, is really sexy ......

[BannedWord]

I'll contribute a couple points here, noting that I'd prefer to steer clear of the political because (a) I expect that philosophically I may sit at the polar opposite viewpoint of the majority (and that's ok with me, frankly, but those discussions have been known to stray far afield from civil discourse far too often) and (b) I have a total distrust of government in general since neither political party gets a pass from me. That being said...

@fskn I really like your comment and view on availability of the generics for the PrEP drugs or opening the generic market wider, allowing importation from other countries, and other solutions that help close the risk gaps. In general, just one issue: Big Pharma. They've been so accustomed to getting their way in the patents for new medications versus the ability to introduce generics after that reasonable point in time to recoup R&D costs for those drugs. And I'll go right back to my initial statement on why, since Pharma has pumped serious money into both lobbying and otherwise plying the pockets of nearly every elected official to ensure they get precisely what they want. And what they want is to keep pillaging the pockets of the US while other nations with public healthcare have set pricing for what is paid for specific drugs. Want to sell the drug in North Elbonia who has nationalized healthcare? They'll only pay for one or two drugs out of all available, and lowest bidder wins. Who picks up the difference? The US who already has the highest per capita cost for healthcare.

Not even talking about how egregiously long patents are to prevent a drug from going into broader distribution. Basically, we're all getting fucked here without even getting a reach around.

@hntnhole can we address the "widely accepted source of reliable, non-judgemental information" for a moment? I'd love to know your views on why you think that exists, and what you actually think that means. If I pick on Joe Rogan for a moment, you can point to a number of specific instances where he provided discussion (I'm not going to call it 'information' yet) on topics such as alternative treatments and the efficacy of cloth makes for COVID that at one time were the subject of ridicule and derision, even censorship and social media squelching/banning but have since been given credibility by the CDC (in the case of masks). So I'd need to ask who the arbiter of the impartiality of information becomes since most discussion has become parochial in nature...and you're shouted down if you disagree. I would add that any information needs to be qualified as "factual and impartial", just like the way that news at one time was not a glorified opinion and focused on the what, who, where, when and how, possibly the why of an event. Who would provide that information? How could we trust it to be reliable, factual, impartial? 

I'd argue you're on the right track with government. But when you have people in power -- Nancy Pelosi, for instance has made massive profits from stock deals that would put Gordon Gekko to shame -- who benefit from this ongoing status quo, you won't see the change with nearly anyone in the current system. Go further and really question and challenge!

And @fskn, as to "coverage through age 25 on a parent's plan was one of the first visible ACA provisions. As a privilege for the politically powerful middle class, it could help shield the ACA from repeal. I'm sure this was a careful political calculation", I'll say this: One of the things that could have benefitted ACA from repeal would have been to ban the implementation of "pre-existing conditions as a barrier to a claim". That could have been done with the stroke of a pen and saved millions from the fear of (a) losing affordable coverage, (b) being able to 'keep their current plan if they liked it', and (c) avoided the alternative of inferior coverage and high deductibles for the ACA plan at ACA rates (which are far enough above markets that people resorted to non-ACA compliant plans at 1/2 or less of their ACA counterparts -- I don't need maternity coverage, so why do I need to have a plan that provides it?). Instead, we got 2,900 pages of what seems to have provided a state-by-state marketplace that benefits...oh, that's right, the healthcare companies! 😃 Seriously, I don't have a problem with the parental plan age extension, but ACA didn't do anything measurable to contain rates that have risen by double-digits annually (I've been in the insurance industry for a few decades, there's other options than how ACA did it that are more beneficial to the subscriber, but that's a different thread).

I appreciate that people can look at this intelligently and explore alternate options. It makes me optimistic about other solutions. I personally think we need to go much, much further. 

[hntnhole]

On 1/31/2022 at 9:29 PM, TheSRQDude said:

I'd argue you're on the right track with government

Well, I had to wait to reply - busy day around here, and I tend to get a bit down-in-the-weeds sometimes 🙄

We, as citizens of this country, need to have some measure of trust in our government on certain issues.  One of these would be on issues of health, wellness, etc.  While there are crackers in government, there seem to be fewer in the various health-care arms of our current administration.  That said .....

In the Congress, we need some major reform.  Being elected to the House or Senate should not be someone's ticket to vast wealth.  There have been hues and cries over the years, and they are completely valid.  Given all the other messes we're dealing with currently, the issue of Congresspersons on-the-take, whether from lobbyists, political organizations, whatever, needs to be reconstructed.  The days of Jimmy Stewart in Washington are long, long gone.  Once Voting Rights are secure, bills to care for the least of these among us (not quite a direct quote) are passed, the SCOTUS pigpen is cleaned up, and the really crucial issues to our Republic are addressed, we should turn to:  1) Term limits, 2) Financial issues pertaining to Congresspersons, NGO's contributions (i.e. bribes) to Congresspersons - both Republikan*, Democratic or Independent.  Progressive or Liberal.  Whatever the label, if they're "serving" us in Congress (as opposed to serving themselves trainloads of cash), then that's what they should be compelled by Law to do.  Apparently, greed has become the norm in Washington, particularly when Congresspersons can run again and again for literally decades.  The issue of jerrymandering is related, but probably not germane to this topic. Having been politically active in City of Chicago politics for a number of years, I know first-hand how much that reform needs to happen.

In essence, I'm endorsing a national re-assessment of our Government, and I am about as far from endorsing conservatism as one could get.  After 200+ years, that's not so unimaginable.  I see the Constitution as a crucial document of great importance, since our Government is based on the precepts laid down within it.  That doesn't mean it should never be updated, obviously.  Glaringly, the 2nd Amendment needs major surgery, but there's plenty of updating needed throughout.  It will take sincere, honest discourse amongst the citizens of our country to start righting these wrongs, which seems impossible these days.  How we do it, I don't have a road-map.  But, it's up to each of us to do what we can.

On 1/31/2022 at 12:44 AM, fskn said:

On 1/31/2022 at 12:44 AM, fskn said:

Political changes aside, what do you think about medical changes, namely, relaxing the requirements for prescriptions and testing, only for populations who would otherwise never use PrEP?

I think the "medical" area of the Government has become too large, too unwieldly to act judiciously.  There are too many people on the take from Big Pharma to effect fundamental change in focus.  One thing about bureaucracies is, they tend to get fat and lazy, issuing "guide lines" to more bureaucrats on lower levels - in our case, State Governements - and assume they will be followed.  Yet another layer of molasses to grind through.  Another thing about these collections of civil "servants" is, they tend to develop into a "take care of myself first, then the rest of the citizenry" mindset.  I'm not saying all the people working for Government are corrupt - far from it.  It's more like a creeping, gradual drift.  Which is why we need a more holistic approach to reforming these institutions of Government.  However well meaning, these outfits are not equipped to do it themselves.  Thus, it it's to be done, it must be via the electoral process, starting at the local community level, proceeding through the ranks of calcification to the Federal Government.  Some today think that armed revolt (called for yesterday by Cheeto-Head - he of that ridiculous pompadour - I could go on and on, but that's for a different place - and that would wind up with tragic consequences.  Somehow though, the health-care arm of the Government simply must be reformed to include the welfare of every damn person on this continent.  Every single one.  Regardless of race, creed, origin, who they fuck and how often, on and on.    

There's no quick fix here; things have been oozing along for so many years it will take a general "shake-up" to bring these much and sorely needed reforms.  I wonder if it's already too late.  But I'm an optimist - a fool, maybe, but I actually believe we can right these wrongs together - as an educated citizenry.  

On 1/31/2022 at 9:29 PM, TheSRQDude said:

How could we trust it to be reliable, factual, impartial?

Well, I'm sorry to say that at present, we have to assess for ourselves how factual the information we get actually is.  Frankly, I do trust in information from the CDC regarding covid - however lugubrious their testing regimens are.  I don't think some of the arms of Government are quite as fucked up as some others, and they're the doctors, not me.  So, I do what Fauci tells me to do.  I have to place at least some trust in our Government.  

When we press our concerns/issues firmly and consistently, together as one, we will get some of these folks attention.  As far as I'm concerned, we could start pressing Congress to announce that there was no 45th President of the United States.

*intentional

[BannedWord]

On 2/2/2022 at 2:53 PM, hntnhole said:

Once Voting Rights are secure, bills to care for the least of these among us (not quite a direct quote) are passed, the SCOTUS pigpen is cleaned up, and the really crucial issues to our Republic are addressed, we should turn to:  1) Term limits, 2) Financial issues pertaining to Congresspersons, NGO's contributions (i.e. bribes) to Congresspersons - both Republikan*, Democratic or Independent.  Progressive or Liberal. 

Having been politically active in City of Chicago politics for a number of years, I know first-hand how much that reform needs to happen.

That doesn't mean it should never be updated, obviously.  Glaringly, the 2nd Amendment needs major surgery, but there's plenty of updating needed throughout.  It will take sincere, honest discourse amongst the citizens of our country to start righting these wrongs, which seems impossible these days.  How we do it, I don't have a road-map.  But, it's up to each of us to do what we can.

Well, I'm sorry to say that at present, we have to assess for ourselves how factual the information we get actually is.  Frankly, I do trust in information from the CDC regarding covid - however lugubrious their testing regimens are.  I don't think some of the arms of Government are quite as fucked up as some others, and they're the doctors, not me.  So, I do what Fauci tells me to do.  I have to place at least some trust in our Government.  

There are definitely areas where we both agree and disagree in this post, and I've shortened this since I still don't quite have the knack for multi-quotes on this site. No personal offenses made in any of my comments:

Voting Rights/Term Limits, et al. Foremost, one of the glaring things is how voting rights has been weaponized, and I've actually participated in clear voter fraud litigation against government entities where it's actually occurred and no one wanted to establish correct oversight (or were too content/lazy with keeping status quo). It's disingenuous to state that asking for identification to vote is disenfranchising to people who already need to produce identification to do just about everything else from applying for a driver license, receiving government benefits (medicare/medicaid, public assistance, social security, the list is. far too long to state here). And trust me when I tell you  I've seen the evidence of the same individuals voting on multiple occasions with election officials turning a blind eye because it suited them just fine. Moreover, the right to vote has been a privilege granted to legal US Citizens, and that's being trampled by opportunists weaponizing the specter of Jim Crow to say that people are being kept from voting. Really? They've just decided that anyone in the City of New York can go to vote regardless of their citizenship. Given the closeness of the last election, packing voting booths with people of dubious legal status in this country and allowing them to vote does what to the rights of those who are conducting themselves in a law-abiding manner? Go anywhere else in the world and see if you can vote in their elections.

As for Term Limits, that is already built into our system. It's called VOTING. We have the right to keep a representative as long as we want...or not...by participating in legal voting. You want some asshat politician of any party out of office? Vote. Don't want to vote? Don't bitch about it. Keep in mind that I lived in New York, and you could put any idiot on the ballot and they'd likely win (and have). Just make sure they're on the Democratic line on the ballot. I mean look at AOC, the woman making $175K and still wants the average American paying off her student loans. Really?!? 

City of Chicago. I'm pretty sure you can still vote there, right? I mean there's an entire legion of World War One vets who remain politically active to this day there. 😂🤣 Seriously though, I agree that reforms need to take place, Chicago is a great example of that. I've loved the city every time I've visited. It's just really difficult to feel safe there, and Mayor Lightfoot hasn't exactly shown herself capable of doing much about the problems. We need better choices. (I'm only partly joking about Chicago's "Vote Early & Often" reputation).

Constitution/SCOTUS. There are three branches of government for a reason. They're supposed to be a check-and-balance on each other, or at least that's how the framers envisioned it. While I don't think it's possible to keep SCOTUS from being a political football, the process of selecting and confirming justices is as mercurial as are the people sitting in the White House and Senate. Anyone remember Robert Bork and how he got basically lynched in Senate proceedings? Almost happened to Clarence Thomas as well. You can cite any politician going both ways on positions on how nominations should be handled. But getting back to my point, there are Executive, Legislative and Judicial branches for a reason: We don't legislate from the bench. That's for Congress to do, and if citizens want something to change, there's a great way to do it called a Constitutional Amendment, something voted on by Congress, signed by the President, and adopted by at least 38 states. Don't like the law? Great. Change it. 

And speaking of 2A, especially with the current lynching of law enforcement amidst cries of "Defund the Police", defending yourself becomes all too much a matter of every man for themselves as even law enforcement has done the Great Resignation based on having targets on their backs doing what we've asked them to do: Protect us. I almost can't blame them for giving up. Does that mean that I don't think there are some really bad actors in law enforcement? Damn right there are. Let's make sure we deal with that in the correct way, but not in a totally reactionary/start needless riots and looting/shoplift from any shop we want and disadvantage other potential allies way. I've met really shitty cops too and agree some of them are the picture of the kids who got bullied in the schoolyard getting their revenge on people. Address the real problem. Making us totally lawless does the opposite. 

Do we potentially need reform on 2A? I'm not sure. The only solution I have seen from anyone are solutions designed to strip lawful gun owners of their guns and doing nothing to ensure guns are taken out of the hands of criminals, or they're prevented from getting over the border and bringing arms in. So I'd prefer to keep my 45. And compared to our current situation, probably the other 45 as well. 😉 No fan of Trump am I, but Biden makes a huge case for being out of touch and tone deaf to what people find important.

CDC/Fauci. "Wear any mask...oh wait, cloth masks work as well as knitted condoms." Yes, I know we're learning a lot about how to handle a pandemic, but I'm skeptical of the CDC and especially Fauci's claims because some very specific ones ("there was no Wuhan Lab...wait...well, there might have been"). Am I an anti-vaxxer? Nope. Have mine. Been COVID free and taken precautions to a reasonable degree. But two years on, people just want a path forward. I grant Fauci is still muddling through like the rest of us, but I'd have liked to have seen more authoritative voices on the topic than just taking as gospel everything that Fauci says. Or the overt criticism of everyone who isn't vaxxed, regardless of whether there are underlying conditions that a vaccine may exacerbate. Trust but verify.

Thanks for some really great points and a civil discourse.

Peace!

[hntnhole]

And thanks back, SRQDude.  I've been wondering if anyone would pick this topic up.  Briefly:

Voting rights:  Obviously identification is required.  That has become almost universal.  It's the willful and illegal abrogation of these rights that are the danger, on every level of Government.  Apparently, in my district here in FL, many of the election-day volunteers (lots of older ladies) have resigned out of fear for their safety.  So, I went downtown to the registrar's office and volunteered to help at my voting location.  It's at least something I can do.  I'm not suggesting that someone who is not registered should be able to vote.  What I'm suggesting is, we expand who is able to vote, which would broaden, not contract, the voice of the people.  Packing the precincts on voting day with folks not legally allowed would be wrong.  Packing the precincts with legal voters would be the goal.  

20 minutes ago, TheSRQDude said:

I mean look at AOC, the woman making $175K and still wants the average American paying off her student loans. Really?!? 

A perfect example of the rapacious greed.  I have nothing against her politically (can't say I agree with all her positions), but she's just as vulnerable to the greed encrusting Congress.

 

23 minutes ago, TheSRQDude said:

I mean there's an entire legion of World War One vets who remain politically active to this day there

I'm not quite THAT old ..... but I was a small part of the "Machine" for a number of years.  Obviously that old, outdated type of political activity belongs to be ended, and for the most part, it ended with Richie Daley.  If I recall, Ed Kelly was the last of the lot.  Don't forget though, that Cook County Government is the real source of rapacious, rampant greed.  That said, I do remember when around - oh - 4, 4:30 pm on election day - sometimes the graves would open.  That's pretty much long gone now, though.  Lightfood doesn't wield anywhere near the power that the Daley's did.  However, it was Jane Byrne that put a stop to the cops raiding the bars.

Constitutional Amendments:  Of course.  And, what any Amendment alters depends on people voting.  Legal residents who can't be bothered to vote should be sent to Siberia, as far as I'm concerned.  Voting is a "right" AND a "duty".  Far too many ignorant legal citizens that can't be bothered to take care of our Republic, which may well damage it.

2A:  The "defund" stance is simply ridiculous.  I would be for replacing that term with re-fund the police.  Give their non-critical law enforcement duties to other civic entities.  Since we no longer have "officer friendly" walking the beat, there is no real connection between the neighborhoods and their police dept.  The social-support tasks belong elsewhere, not to the cops.  Also, I'm also a Organized Labor supporter, and many police unions need a bit of adjustment.

  I do not believe that gun ownership should be banned wholesale.  I also do not believe that our streets should be awash in them.  Keep your legal guns.  I hope you don't need to use either of them, but it's your right to own them as long as they're legally registered.  Some of these weapons do not belong in the hands of regular citizens, and should not be available to them.  Another item in the bucket to be addressed.

43 minutes ago, TheSRQDude said:

Biden makes a huge case for being out of touch

That may be the case - but I'm not qualified to actually assess his mental capabilities.  What I can say with confidence, is the Senate he remembers is no more.  Whether he grasps that fact or not remains unclear.  His heart is in the right place, but that's not going to be enough.  

CDC/Fauci:  Neither is a bastion of uttermost truth.  What may have been unclear earlier, is that I need to be able to trust someone ... and I settled on Fauci.  

Thanks so much for the reply ... let's continue this, even if no one else will ...... right now though, I really need to get some supper ....

[BootmanLA]

3 hours ago, TheSRQDude said:

Anyone remember Robert Bork and how he got basically lynched in Senate proceedings? Almost happened to Clarence Thomas as well.

As I recall, Bork (a) received a hearing from the Judiciary Committee and (b) received a floor vote in the Senate, whereupon he was not confirmed by the widest margin in Senate history after serious legitimate questions about his judicial philosophy, including his rejection of the Civil Rights Act. The Reich Wing's distortion of his actual record and the subsequent portrayal of this as character assassination is one of the greatest feats in whitewashing history.

[fskn]

May I ask that we keep this thread focused on PrEP barriers, and start (and link out to) threads in other forums for more-than-incidental political discussion?

I think political discussion is a great thing, but it risks drowning out what I hope will become a compendium of reasons why people stop PrEP. Ultimately, that could lead to specific improvements in the way we educate people about PrEP and support them in using it.

Thank you for considering this request.

Edited February 5, 2022 by fskn