Tuesday, November 15, 2016

Treatment to Prevent HIV Promising ― If Key Patients Can Get It

Austin family physician Cynthia Brinson, MD, says identifying candidates for HIV pre-exposure prophylaxis requires setting aside any assumptions physicians may have about the patient's risk for contracting HIV.

Physicians can block HIV spread with a little-known treatment — if they can identify high-risk patients and administer the treatment to them. The questions can be difficult for physicians to ask, however. The questions can be personal, and they can be awkward for a patient to answer; but they are necessary to determine whether a patient’s sexual behavior or drug use puts him or her at risk of contracting HIV (human immunodeficiency virus). When patients are at risk, doctors can prescribe the treatment, HIV preexposure prophylaxis (PrEP), that might curb that risk drastically, reports the Texas Medical Association’s (TMA’s) Texas Medicine magazine.

That's why family physician Cynthia Brinson, MD, strives to get all the information she needs, including uncomfortable-but-pertinent details on sexual behavior, when assessing patients for the Austin PrEP Access Project (APAP). The volunteer clinic provides HIV PrEP to patients susceptible to the virus that causes AIDS.

“I’ve heard many patients say, ‘I don’t want to talk to my physician because [he or she] wouldn't approve of what I’m doing,’ whether that’s true or not,” Dr. Brinson said. “And the physicians are making assumptions by saying, ‘I’ve known my patient a long time, and [the patient is] in a monogamous relationship.’ I think when we make assumptions about the people we know, we’re not really seeing people in the full context of a life.”

In the three decades since AIDS first became the United States' biggest public health scare, panic over the disease and HIV has largely disappeared. But the virus persists, especially in Texas, where Texas Department of State Health Services figures show more than 82,000 people were living with HIV in 2015.

The PrEP pill and treatment can stop that number from growing by preventing people from contracting HIV. Large clinical trials showed consistent PrEP use reduces people’s risk of getting HIV from sex by more than 90 percent and reduces the risk of getting it from drug injections by more than 70 percent, according to the Centers for Disease Control and Prevention (CDC). But many people at high risk don’t know PrEP exists, let alone how accessible it can be. APAP and other PrEP clinics around the state are working to change that ― starting with the type and tone of questions physicians ask patients.

Dr. Brinson said it’s important for physicians to set aside what they think they know about the patient and ask the questions they need to ask. She says when she tries to assess a patient’s risk factors for HIV, she avoids asking leading questions.

“I’ll ask patients if they’re involved with anyone sexually. And if they say no, I might ask them, ‘Well, if you were to be involved with someone sexually, would that be a male, a female, or both?’ and let the patient take it from there,” she said.

Yet physicians might not always ask the right questions because of the demands of a clinic visit or discomfort with taking a sexual history and discussing details of sexual relationships.

Houston adolescent medicine fellow M. Brett Cooper, MD, a member of TMA’s Committee on Child and Adolescent Health, said merely asking patients if they’re sexually active isn't gleaning enough information.

“For the adults right now, you’re missing out on that 18-29 [age group] if you’re not asking, ‘What gender are your sexual partners? Are you having sex under the influence of substances, whether that’s drugs [or] alcohol? How many partners are you having?’ That’s where CDC recommendations for putting people on it [PrEP] come into play, is your behaviors,” he said.

Dr. Cooper said physicians hope to reach the people at greatest risk more effectively. He said minorities tend to underuse many of the available services, and the highest diagnosis rates show up in African-American men having sex with men.

“The theory behind it is that there’s a lot more stigma in the minority communities around [men] having sex with men, whether you identify as gay or not,” Dr. Cooper said. “Then if you show up at a clinic for PrEP, people will look around and be like, ‘I know this person, I know [that] person.’ ”

Dr. Brinson agrees lack of awareness and patient trust prevent high-risk patients from accessing PrEP. She said eradication of HIV is possible, though; the goal of APAP is to see no new infections in Austin by 2020. While PrEP has been successful in gay white communities, she said her clinic has trouble reaching into the communities it would like to reach, such as Hispanic, African-American, and underserved communities.

We must do something to stop this continual infection rate,” she said.

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