By Yen Duong
Although antiretroviral drugs mean that HIV is no longer the ‘death sentence’ it was in the 1980s, the epidemic is not over yet, as 30-year old Charlottean Colin Jack knows well.
“One of my best friends died at 28, two months after his birthday,” Jack said. “I wouldn’t have thought that would have happened to me, seeing ‘Rest In Peace’ on Facebook. It doesn’t really hit home until it’s somebody that you know. … I’m trying to avoid becoming that.”
While dating an HIV-positive man in 2012, Jack began using PrEP, or pre-exposure prophylaxis, taking a daily pill which protects people from getting HIV.
PrEP, which reduces the chances of contracting HIV by 97 percent, is one of three pillars of the Getting to Zero” community plan to eradicate new HIV cases in the county. The plan is spearheaded by public health officials from Mecklenburg County, which was singled out by the Trump Administration as one of 48 hotspot target counties in a national campaign to end the epidemic by 2030.
A three pillar plan
An estimated 6,682 Charlotteans live with HIV today, according to AIDSvu, a website which tracks HIV and AIDS in the U.S. If those patients effectively take antiretroviral drugs for long enough, then they can no longer transmit HIV to sexual partners.
That fact is the basis for Treatment as Prevention, another pillar of the Getting to Zero Plan. Once someone is diagnosed with HIV, they need to begin treatment quickly in order to prevent new cases.
Linkage to treatment dominated the discussion at the May Getting to Zero meeting with public health officials, clinicians and community members.
“We have people who come to us two or three weeks after diagnosis; that is the weakest link right now,” said Dr. Marc Johnson of Atrium Health. “We can do rapid start in any of the clinics right now, but we don’t have […] people to do bridge counseling.”
While some of the program’s $350,000 of state and county government funding goes to medical reimbursements and outreach to providers who may be unfamiliar with PrEP, a large chunk of that money goes to education and testing, the last pillar of the plan.
Bus, radio and social media campaigns advertise the PrEP program along with safer sex practices. Public health regularly offers education and free HIV tests at sites across the county, including a homeless shelter, the county jail, local colleges and even a Walgreens.
“One of the things that we did identify very early on is education around behavior change,” said Matthew Jenkins, who manages HIV/STD community services for the county health department.
“Because if I’m constantly coming back for an HIV test but you’ve not taught me how to use a condom, then I’m continuously at risk and I will constantly come back.”
Jenkins added, “Sometimes we talk about HIV and we don’t mention syphilis. Between 2013 and 2017, the number of syphilis cases [in Mecklenburg County] have doubled.
Outside Mecklenburg, residents should reach out to their local public health department for free, confidential testing.
“HIV and STIs go hand in hand. When we educate we should be educating about all of it at the same time.”
The 54-page plan, which began as a conversation between county commissioners and community members in 2015, also considers social determinants of health, such as housing, access to food and transportation, along with mental health and substance abuse issues.
“Getting to zero is not just about putting a free pill in the hands of somebody who’s at risk for HIV,” said certified physician assistant Wesley Thompson, who said his clinic includes about 450 patients on PrEP, with about 50 enrolled in the county program. “I can’t remember to take my pill every day, if I don’t know where I’m going to put my head… Those five [social determinants of health] are as big a factor, if not more, than getting that pill in their system.”
Nationally, only about 10 to 20 percent of the 1.2 million Americans recommended for PrEP—men who have sex with men, people who use intravenous drugs and people who have sex with HIV-positive people—use it.
“If you living this lifestyle, you have to assume everybody has HIV, as messed up as that might sound,” Jack said. “But you need to protect yourself first, you need to do due diligence.
It is scary. But it’s like I always tell people, ‘You gotta love yourself first. Can’t nobody take care of you like you can take care of yourself.’”
Drug pricing affects HIV treatment
PrEP requires a prescription from a provider and regular labs and HIV testing. For the county’s two-year-old PrEP program, which now serves 127 patients, the public health department reimburses six clinics for those medical services. The state will expand the PrEP program to Gaston, Cabarrus, Union and Hanson counties, Jenkins said.
In the wake of Trump’s plan, the pharmaceutical company Gilead announced this month that they would donate enough pills to treat up to 200,000 low-income, uninsured people for 11 years. But it’s unclear how or if the announcement changes anything, because uninsured and low-income people can already get their medications for free via Gilead’s patient assistance program, which the county helps patients apply for.
Gilead, which manufactures Truvada, the only PrEP drug available in the U.S., has recently come under fire from the U.S. Congress for its pricing. University of California San Francisco scientist Robert Grant, who did some of the original research showing that Truvada could prevent HIV, testified at a meeting of the House Committee on Oversight and Reform last Thursday.
“I believe that the root cause of low PrEP access is the high price of the medication. PrEP can be manufactured and distributed, including a profit, for about $6 per person per month,” Grant told the committee. “Gilead charges more than $2,100 per person per month, a 35,000 percent markup.”
Despite the cost, investing in PrEP makes economic sense, Thompson said. The average HIV-positive patient spends about $36,000 per year on health care due to HIV or its complications, and 50-some years of an HIV diagnosis can add up.
“When San Francisco implemented countywide PrEP at no cost, they went from 3,000 cases a year to less than 200,” Thompson said. “[Here in Mecklenburg,] there could be a 14 to 18 percent drop, which is significant. It may not sound like a lot, but every case that we prevent is saving the system a potential almost $2 million medical bill over the next half a century.”
Presumably the federal government will send funding to the hotspot counties and states, but there’s been no news so far in Mecklenburg.
“None of us know what that looks like yet,” Jenkins said. “I know that there was conversations around looking at the federally qualified health centers, funneling it in that way, but there’s been no specifics.”
Correction: This story has been changed to reflect that Wesley Thompson is a PA-C, or certified physician assistant, not a medical doctor.
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