Seven years after the U.S. Food and Drug Administration approved the drug Truvada to block HIV transmission, many doctors on Long Island still have never prescribed the medication, and some have not even heard of it.
Training set to launch in the next several weeks will educate Long Island physicians, nurse practitioners and physician assistants not only about the drug and its benefits, but also about how to make patients comfortable sharing details of their sexual histories, which is key to getting the medication to those who need it. The training also will cover financial-assistance options for the drug, which has a list price of $1,758 a month.
The hope is that increasing doctors’ knowledge of Truvada for PrEP — commonly known as PrEP, for pre-exposure prophylaxis — will increase the number of Long Islanders who use the medication. PrEP reduces the risk of HIV transmission from sex without condoms by 99 percent when taken at least four times a week, according to the federal Centers for Disease Control and Prevention. It reduces the risk of HIV transmission among people who inject drugs by 74 percent to 84 percent.
A report released July 12 by the CDC found that Long Island gay and bisexual men most at risk for HIV transmission were less likely than men in most of the other 19 urban areas studied to know about PrEP and get a prescription for it. Eighty-four percent on the Island were aware of it, and 18.5 percent were using it.
A separate CDC report on heterosexuals at increased risk for HIV found that in 2016, only 6.7 percent of those surveyed in 17 urban areas — including Long Island — had heard of PrEP and only 0.2 percent were using it.
Nationally, only 18 percent of the 1.1 million people of any sexual orientation who the CDC estimates are at high risk for HIV and should consider PrEP are prescribed the medication, according to the drug’s manufacturer, Foster City, California-based Gilead Sciences.
African Americans and Latinos, who made up nearly 70 percent of new HIV diagnoses nationwide in 2017, were far less likely than whites to receive PrEP prescriptions in 2016, a CDC study released last year found.
Among those for whom the CDC recommends PrEP are HIV-negative men and women in an ongoing sexual relationship with an HIV-positive partner; gay and bisexual men who are not in a monogamous relationship with an HIV-negative person and have had anal sex without a condom in the previous six months, and people who inject drugs and have shared needles or other drug equipment in the past six months.
The Long Island training will include six hours of webinars and a two-hour, in-person workshop, said Dr. Joseph McGowan, medical director of Northwell Health's Center for AIDS Research and Treatment in Manhasset. He will deliver the training with Dr. Antonio Urbina, a Manhattan doctor and medical director of the state AIDS Institute’s Clinical Education Initiative.
About 50 doctors, nurse practitioners and physician assistants have expressed interest in the training, McGowan said. Outreach has been across the Island, and among health care providers approached are those who treat patients in communities with high HIV rates and those who participated in a survey last year on PrEP, he said.
McGowan said many doctors who believe they have no patients who fit CDC guidelines for PrEP are either not asking patients about their sex lives or are not doing it correctly.
After the training, doctors will “be able to identify people who might need PrEP but won’t come in and ask for it,” McGowan said. “The people who knock on your door and ask for PrEP, mostly those people have already gotten on PrEP.”
Karen Haslam, a community health worker who discusses PrEP with people getting HIV tests at health centers operated by the nonprofit Westbury-based Long Island FQHC, said patients often are reluctant to discuss their sex lives, and “doctors are very uncomfortable talking about something so personal.”
Critical to obtaining honest, accurate information is creating “a warm, welcoming environment where someone would want to say, ‘You know what, I am having sex with X number of partners,’ or ‘I’m having sex without using condoms,’ ” said Anthony Santella, an associate professor of public health at Hofstra University. “Most people aren’t just going to offer up that information.”
Santella oversaw a 2018 Hofstra survey of 341 Long Island health care providers that found three out of four had never prescribed PrEP, and 14 percent had not heard of it.
Some doctors on Long Island had previously received limited, one-hour training on PrEP, but that focused primarily on the drug itself, rather than matters such as eliciting honest information from patients on their sexual histories and drug use, and the practicalities of implementing a PrEP program, McGowan said. The survey illustrated the need for more training, he said.
The survey also found that 28 percent of health care providers believed “behavioral interventions” should be tried before PrEP.
McGowan said the training will encourage doctors to use behavioral interventions, such as encouraging condom use, in combination with PrEP.
But, McGowan said, there always will be some people who engage in risky sexual and drug behavior, and “it would be really unethical to withhold a treatment that has been proven to be so effective in preventing HIV infection,” he said. “If we see a [high-risk] person tested for HIV in a doctor’s office and tested negative, and then we see them a year or several months later and now they’ve tested positive and they didn’t get offered PrEP, to me that’s not only a missed opportunity, but it’s essentially malpractice.”
McGowan said a priority for the training is recruiting doctors who serve people living in the “hot spots” on the Island of high HIV prevalence, all of which have large African American and Latino communities.
The 2018 CDC report found that African Americans and Latinos were less likely than whites to be aware of PrEP and to use it, as were low-income people, those without college degrees and people who had not visited a health care provider in the past year. Lack of access to health care is a major reason that black and Latino HIV rates are so much higher than the rate for whites, McGowan said.
Santella said training a limited number of health care providers isn’t enough; more aggressive outreach to people at risk for HIV is needed.
A barrier to PrEP has been the cost. During a May congressional hearing, Democrats blasted the company, saying CDC research and tens of millions of dollars in government grants proved Truvada for PrEP blocks HIV transmission, according to a story published in The Washington Post. Yet the company is, Rep. Elijah E. Cummings (D-Md.) said, abusing its monopoly over the drug and charging “astronomical prices,” according to The Post.
Gilead CEO Daniel O’Day said in the hearing that profits fund research. Gilead said in a written statement to Newsday that the company provides assistance to PrEP users with financial need. The drug is covered by Medicaid in New York, Medicare Part D and many insurance companies.
Gerald Field, a nurse practitioner at the Northwell AIDS center, said Northwell helps patients navigate financial-assistance programs. He said knowledge of PrEP is growing on the Island.
“Patients refer other patients," he said.
To obtain information on Truvada for PrEP — including on financial assistance — and HIV testing, call Northwell Health at 516-713-8060 or Stony Brook Medicine at 631-559-6138.
PrEP BY RACE AND ETHNICITY
An October 2018 U.S. Centers for Disease Control and Prevention report broke down by race and ethnicity the Americans who could most potentially benefit from PrEP in 2015:
43.7 percent black
26.3 percent white
24.7 percent Hispanic/Latino
Yet in 2016, according to an analysis of about 42 percent of PrEP prescriptions nationwide, those who actually received the drug were:
11.2 percent black
68.7 percent white
13.1 percent Hispanic/Latino