Other than establishing that Jeff was gay and administering an HIV test, it appeared to him that his New York City primary care doctor did little to address what he considers a paramount health concern — HIV prevention.
“I got the sense [my doctor] didn’t really know about it. It was a general message I was getting: ‘Protect yourself,’” Jeff (a pseudonym he used so he could discuss his sex life openly) told Al Jazeera.
Condoms, it appeared, were the only answer.
But after taking time from his busy schedule as a college student to consult an HIV health care specialist, who discussed his sexual history with him frankly and at length, Jeff started taking Truvada — a controversial new antiretroviral drug said to help prevent HIV infection.
While health authorities across the nation advise gay men to seek appropriate HIV-related health care, advocates say gay men have to go the extra mile to seek out information it isn't that difficult to impart.
Truvada has been at the center of a recent flurry of debate as prescriptions are starting to “snowball” in U.S. gay life hubs like Seattle and New York, according to health care professionals.
Some AIDS rights advocates like AIDS Healthcare Foundation President Michael Weinstein have come out vehemently against Truvada — also referred to as PrEP — saying test studies have offered insufficient proof that the drug really prevents HIV transmission and that government sanctioning of the drug is tantamount to using young gay men as “guinea pigs.”
“This will lead to more infections,” said Weinstein. “You don't have to give gay men more excuses not to use condoms.”
Three gay men in their 20s and 30s who take Truvada, a daily pill that industry analysts say will eventually become a monthly injection, told Al Jazeera that they occasionally have sex without condoms. One man added that he is no more likely to have sex without condoms than he would be if he were not on the drug. While Truvada is, according to some reports, 99 percent effective in preventing HIV infection, it does not protect against other sexually transmitted diseases.
Kathy Brown, HIV Program medical director at the Seattle-based health care nonprofit Group Health, disagrees that Truvada will promote risky behaviors.
When Brown prescribes Truvada to her patients, she says, “they feel like they have more control over their risk and in some cases may take less risks, because they no longer have this fatalistic thought that ‘it doesn't matter what I do, I'm going to get infected sooner or later.’”
According to Brown, though, regular use of Truvada presents other risks. Among a slew of potential side effects, Brown says, some patients have experienced nausea and “severe kidney problems” that appear to have reversed since they stopped using the drug. Others have reportedly complained of resulting health complications affecting blood, liver and bone density.
The notification on Truvada at the Centers for Disease Control and Prevention website does not mention kidney problems associated with the drug. It suggests that patients discuss taking it with their physicians, but for many, that’s not proving very helpful.
A meaningful dialogue
Faced with new options on HIV prevention, studies show, the medical community is largely ill equipped to help gay men make informed decisions about their sexual health.
Nearly half of primary care providers (PCPs) interviewed in a report released last week by the health care advocacy group Health HIV said they do not provide clinical HIV care, and that a lack of knowledge about HIV treatment and prevention is “a significant barrier” to providing care.
The study also found that many HIV specialist PCPs are approaching retirement age, with 55 percent over the age of 50.
The findings reveal that although the Affordable Care Act stands to insure many HIV-positive Americans who have faced often insurmountable difficulties finding affordable health care, the number of physicians with knowledge of HIV health care advances is starkly low, with a large majority concentrated in major U.S. cities on the coasts.
PCPs all learn how to engage with patients about living healthily with HIV or preventing it, said Brown.
But “discomfort” with the number of new medications to prevent and treat HIV makes some doctors uncomfortable with prescribing them, she said.
“The prevention of HIV is similar [to treating HIV]. It uses an HIV medicine — most of the primary care providers don't know about how to prescribe it,” she said. “With Truvada, what we found is that now that insurances are covering it, the problem is for primary care to provide it and educate the patients who ask for it.”
Brown said some state health departments have been trying to instruct doctors in how to prescribe Truvada and offer better counseling on HIV issues. And many state health officials are devising plans to more effectively do so.
“Look, this isn't difficult to prescribe,” she said. “It's not nearly as difficult as managing someone with HIV.”
Brown also blamed social stigma surrounding doctor-patient conversations on sexual history for a lack of adequate HIV-related health care from PCPs.
“Some of the biggest barriers for PCPs is they have to honestly talk to patients about their risk factors and what kind of sex they are having,” she said. “Even though they go through schools and learn that, it's difficult unless you're doing that regularly. If they [patients] are gay, you have to talk about what kind of sex they have with them. They may unknowingly be judgmental.”
Jeff had been dating an HIV-positive man, and wanted to bolster HIV-prevention methods to alleviate anxiety that had haunted their sexual relationship.
But his PCP never learned that.
“When I started seeing my primary care provider, there was little talk about sexual activity,” Jeff said. “The relationship that’s established isn’t conducive to that kind of conversation.”