Monday, January 9, 2012
BEYOND SAFER SEX: THE LOWDOWN ON PEP, PREP, AND THE ISSUES "UNDER THE SKIN"...
(Photo: Michael Ramos of The Men's Sexual Health project)
The foundation of HIV prevention has always been education: getting the proper information to the population who needs it the most. The next step is incorporating that knowledge into our daily lives. While HIV prevention does indeed include abstinence, smarter sex, and/or risk reduction, there is more that sexually active adults should know about. One of them is PEP, which has recently come into greater awareness among more enlightened health care practitioners who work with sexually active gay men. What is PEP? It stands for “post-exposure prophylaxis“, and it means taking antiretroviral drugs AFTER possible exposure to the HIV virus, to reduce risk of seroconversion. PEP is not a new phenomenon. It has been available for well over ten years to health care workers who, for example, get accidentally stuck with a needle when drawing blood or giving injections. PEP first became available to the public about 2003. According to the Centers for Disease Control, there is compelling data to suggest that PEP, used for about a month after exposure, is effective. A three month and a six month follow-up HIV test is recommended.
The Men's Sexual Health Project (M*SHP) promotes sexual health among gay and bisexual men in NYC. Their core goal is to make sexual health testing and counseling easily accessible, convenient, and sensitive to the needs of our community. M*SHP does this by offering free HIV/SDI (sexually transmitted infections) testing and education at various locations, including Bellevue Hospital and various after-hours NYC men’s only clubs throughout the year. They also offer these services at such events such as the annual Black Party. In March of 2011, M*SHP launched their own program to offer PEP, named Project 36:00. The project gets its name from gets the number “36”, which is how many hours M*SHP believes you have after the exposure for PEP to be effective-- although it goes without saying that treatment should start as quickly as possible. It is worth noting, incidentally, that The CDC believes that initiation of PEP up to 72 hours may also be effective as well. Again, however, “the sooner, the better”.
Michael Ramos, MSW, is a Research Coordinator at NYU Langone Medical Center and Program Supervisor of M*SHP since 2007. The social worker, activist, and father of a young son has been seeing clients for four years. He has counseled and tested a seemingly countless number of men, and has no doubt heard their equally countless number of real-life stories. A bona fide expert in the field, Michael spoke to me about PEP:
Although your local emergency room may offer PEP, Ramos tells me that the ER might not be the most ideal pathway for care. For starters, the ER staff may not be trained on either PEP and/or the individual‘s need. Some men might even walk away without getting PEP, because the ER staff may not know how to dispense it, or may even minimize the perceived risk from the exposure. In addition, as anyone who has been to the ER knows, it can be crowded there, with a hierarchy of needs as to who gets seen fastest. Lastly, the client may not have insurance. Project 36:00 is a more streamlined process which bypasses the ER and even saves money. In addition, the client gets the medication at a much faster rate-- sometimes within the hour. How does it work? The client calls the number (501-5200) and goes through a series of automated questions and prompts. A MD will do a phone assessment to determine the risk. If he decides that the client is a candidate for PEP, he will call in a couple of days’ worth of medication to Walgreen‘s, the cost of which is covered by a grant to M*SHP. Shortly afterward, the client will go for the “M*SHP package”, which includes HIV and SDI testing, liver function testing, and sexual risk assessment. At that time, the client will then receive a prescription for medication for the rest of the month… and be scheduled for a follow up visit with M*SHP six weeks later. By Michael’s estimates, over 90 percent of the guys come back for follow-up tests.
What about PrEP? PrEP is short for “Pre Exposure Prophylaxis”. The goal is HIV prevention by which HIV negative people who are at high risk take antiretroviral medication daily to try to lower their chances of becoming infected with the virus if they are exposed to it. According to The CDC, PrEP-- like PEP-- has been shown to be effective in men who have sex with men. Through the course of our conversation, Michael noted one of his past clients who definitely was a candidate for PrEP, based on his sexual behavior and life situation. However, he states, “In my personal opinion, I am not a fan of it!” Why? While he agrees that PEP, PrEP, and smarter sex practices are indeed effective for HIV prevention, Michael believes that these are only part of the solution…
Ramos tells me, “HIV is a psycho-social disease, with underlying issues of homophobia, stigma, poverty, access to health care, and mental health issues like anxiety and depression. If we don’t address these issues head on, then prevention is never going to work, because it won‘t be long-lasting. If we can‘t talk about sex openly, and we can‘t discuss our relationships because longstanding institutions are rejecting our relationships from the get go, then that causes stress, and it’s like a domino effect: I’m not comfortable with my sexuality, and I am lonely and depressed, and then I am meeting someone, and I feel connected with this individual in some way for that moment, and he or she is saying all the right things… and the next thing I know, I am having unprotected sex. Does that make me a PrEP candidate? I don’t think so.” Another issue worth exploring is, WHY do we have unprotected sex?
Ramos offers, “What does ‘unprotected sex’ mean for that individual? Is it an isolated incident, or does it happen regularly? We stigmatize sex to begin with, and that adds another layer to the problem. People are not going to be honest about their sexual practices if we are stigmatizing unprotected sex. If the unprotected sex is an isolated incident, then chances are it was individual circumstances that led to it: depression, a bad day-- psychosocial issues that trigger a vulnerability, which then triggers the event that took place. PrEP is not going to solve that. PrEP is, ‘Take a pill every day.’…just like, ‘If your positive, take a pill every day because we need to have your viral load suppressed, so that you won’t infect other people.’ And yes, if you positive, your viral load should be suppressed. That‘s the goal of treatment. But on the other side, we are saying, with PrEP, “OK, you are negative and you are risky, so be on medication.” There‘s something morally wrong with that.” He adds, “We need to have serious dialogue, and change how we see sex and sexuality, and discuss it openly… but not just with gay guys. It should be global. We let religion and politics influence what is medical.”
Part of the problem may be lack of funding for HIV negative men who may be at risk. Michael tells me, “This is my issue with funding, and we really need to look at it. When you look at AIDS services organizations in general: In taking care of the positives, we really neglect the negatives, like those at risk for becoming positive. There is a surplus of services for HIV-positive people… but if I am an HIV negative gay man, and I am in danger of losing my house, and I may have substance abuse issues, or I may be depressed and I may need to start doing therapy, then I cannot turn to AIDS service organizations. The first question they will ask me is ‘What’s your status?’, because they are servicing positive people. If you are positive, they will immediately dispatch a case manager for you, you will immediately have a social worker, and you will immediately have a therapist and psychiatry if you need it. It immediately triggers all these services. But If you are negative, all they can do is test you for HIV and refer you out. Refer you WHERE? To private practice? To a low-cost mental health service, which may not be as adequate or may not be as gay-identified? This is a big problem! If we can have organizations that mirror the current organizations that we have for those who are HIV positive, and have the same services for those who are HIV negative, I think we might see a reduction of HIV infection rates… and then we won’t need PrEP or a lot of other medical interventions. Again, we need to address the psychosocial issues that comes with the disease, and we are not doing it. We are just putting a Band-Aid on the problem, and creating these interventions that are not sustainable and are short-lived. My dream is to establish mental health services for those who need it… even just on a short-term basis!”
Michael Ramos and I share the same opinion about HIV/AIDS awareness: It’s equal parts “body and soul”!
Do you think you have been exposed to HIV? Call the Project 36:00 number at (646)501-5200
Learn more about The Men’s Sexual Health Project at:
An interview with M*SHP’s Dr. Demetre Daskalakis:
A personal plea to get tested by Jed: