When Arthur Banks, 47, first heard a radio ad about a pill that could prevent HIV, he thought it was a scam.
When taken once a day consistently, the pill — marketed as PrEP — could prevent HIV in more than 90 percent of cases, the ad told him.
“I couldn’t believe it. I went in and found out it wasn’t a scam,” said Banks, who has now been on PrEP for the past year. “For me, it made sense. I have an active sex life and I thought, why not protect myself? You never know what your partner has done in the past.”
In a city that has consistently been in the top five in the country for the number of new HIV cases, health workers in New Orleans are pushing to expand access to PrEP, believing it’s the key to preventing the new infections that have kept the city at the epidemic’s forefront for too long.
In recent years there has been a strong marketing push for PrEP in billboard ads across the city and the state. At the state level, DeAnn Gruber, the STD/HIV Program Director for the Louisiana Department of Health and Hospitals, recently spoke about the state’s marketing efforts of the preventative medication through social media apps as well. Additionally, the department is set to launch a program called TelePrEP this spring that will allow potential candidates to talk to a provider through an online platform so that they can get a PrEP prescription remotely.
“If there is an area of the state where the individual may not be familiar with the provider, or able to find a provider who is comfortable prescribing PrEP, it may save them from having to travel,” explained Gruber.
Health workers say this multi-layered effort is necessary, especially in the South. PrEP adoption has lagged here compared to other parts of the country, even though southern states account for 30 percent of the epidemic in the U.S., according to AIDS.gov.
PrEP has been available since 2012, when the Food and Drug Administration approved use of the anti-HIV medication to lower the risk of someone getting infected with the virus. Taken on a daily basis, the medicine can reduce the risk of getting HIV from sex by more than 90 percent. Among people who inject drugs, it can reduce the risk by more than 70 percent. It works by blocking the ability of the HIV virus to attach to T-Cells.
The use of anti-retrovirals as a preventative measure against HIV is well-known within the LGBT community, to whom PrEP has been traditionally marketed. In larger markets such as New York City, where PrEP has been made more widely available since 2012, the number of new HIV cases has steadily declined in recent years. Data showed that new HIV cases declined by about 2,000 in New York City between 2012 and 2016, coinciding with the approval of PrEP and other preventative measures such as routine HIV screenings being made more available.
Efforts to match those numbers in Louisiana are hindered by several factors including poverty, access to care, poorer health outcomes, stigma, racism, homophobia and lack of sexual education. Louisiana has been in the top five states for the highest HIV rates compared to other states for a number of years. Last year, New Orleans came in second and Baton Rouge third in the U.S. for high case rates compared to other large cities, according to the Centers for Disease Control and Prevention.
Health care providers have focused on getting PrEP to high-risk groups including men who have sex with men, people engaging in high-risk sexual behavior such as condom-less sex with multiple partners, those who have a history of sexually transmitted diseases, or are having sex with a partner diagnosed with HIV who is not being effectively treated.
Bruce Hinton, a physician’s assistant with CrescentCare, adds to that list that living in a high-prevalence HIV area like New Orleans should also be considered a major risk factor.
He recalled how in one day in February three newly diagnosed patients were put on HIV medication in one day at the clinic.
“New Orleans has such a casual attitude about sex that we have seen HIV rates explode. When you have three people in one day put on HIV medication it’s an epidemic,” he said.
According to current estimates of diagnosed HIV cases in New Orleans, approximately six percent of the population living in the 70119 ZIP code where CrescentCare‘s testing site is located at 3308 Tulane Avenue are infected with HIV.
“I tell my patients if you fall under at least of the risk factors you are a candidate for PrEP. By living in New Orleans, you automatically fall under one of those risk factors,” Hinton said.
Traditional marketing of PrEP has been geared primarily towards men who have sex with other men (MSM). The use of the prevention pill has increased in the United States but health providers still have their work cut out to increase its use among minorities.
Although the number of patients on PrEP has grown to approximately 77,000 in 2016, almost 75 percent of those patients were white. Only 10 percent were African-American, and 23 percent were women, according to data provided by the drug manufacturer Gilead.
That’s despite the fact that minorities are seeing soaring rates of HIV diagnoses: A 2016 CDC report noted that if current HIV diagnoses rates persist, about one in two black men who have sex with men and one in four Latino MSM will be diagnosed with HIV during their lifetime.
“We need to make sure that the people on PrEP mirror the people most at risk of being infected,” Hinton said.
In New Orleans this includes even individuals who wouldn’t traditionally be considered high risk, such as heterosexual women.
“Women represent about 25 percent of the HIV epidemic, with African-American women being disproportionately affected,” explained Catrina Coleman, a health educator and one of the people leading outreach efforts about PrEP for CrescentCare in New Orleans. “This is the only HIV prevention that is completely in control of the woman. If I could stand outside handing out information about PrEP all day I would.”
Her main marketing tool is word of mouth. She has visited beauty salons to talk to stylists about it in the hopes they will spread the word to their clients.
The reaction from the women has been a combination of shock and dismay.
“They tell me, “Why weren’t we informed? Why wasn’t this communicated to us before?” she described.
Yet another barrier to HIV prevention is the primary care doctor who is uninformed about PrEP and what it can do, according to Dr. Stacy Greene, the associate medical director and infectious disease specialist with St. Thomas Community Health Clinic.
Patients who might benefit from PrEP are not likely seeing infectious disease specialists, he explained.
“Primary care providers are the first point of contact with this patient population, but they aren’t having these conversations. There is so much fear surrounding HIV, people are afraid to go to the doctor and ask about PrEP,” Greene said. “They need to start breaking down these doubts.”
He estimates that about 33 percent of primary care providers are not knowledgeable about PrEP. There are also providers who know about the medication but aren’t comfortable prescribing it because they feel like it is out of their scope of practice to prescribe it, he added.
The clinic held a PrEP symposium in New Orleans in March for primary care providers across the state to discuss the HIV epidemic and prevention efforts geared to primary care providers.
“If more family physicians and other primary care providers feel comfortable prescribing PrEP, this strategy for reducing HIV pervasiveness may reach more people who are vulnerable to infection,” Greene said.
For another patient who is prescribed PrEP through CrescentCare, the pill has meant consistent access to healthcare, because patients have to be screened for STI’s four times a year to be on PrEP. The 29-year-old woman chose not to be identified for this article because she has not spoken to her family about her work in the sex industry over the past four and a half years.
“Sex isn’t this thing where I have to worry about hurting myself,” she said. “I think I have a much healthier capacity for being sexually active. I still use condoms, I have sexual health conversations, I am still careful and guarding my health. This is something where I feel I have a safety net.”