BY KAYLEE POCHE May 6, 2019 – 10:00 am | Photo: Cheryl Gerber
New Orleans — along with Baton Rouge and Louisiana as a whole — has consistently led the country in the number of HIV cases relative to its population. Total HIV cases continue to rise in the New Orleans area, but the number of new cases has declined in recent years due in part, doctors say, to a preventative medication and increased services.
According to the New Orleans Regional AIDS Planning Council (NORAPC), the total new HIV diagnoses in the New Orleans metropolitan area in 2013 were 523. In 2017, that number was down to 354, with decreases each year.
Dr. Jason Halperin, a physician at New Orleans health clinic CrescentCare, says as long as the number of new diagnoses are going down, rising total cases are actually “a positive thing.”
Since HIV is treatable but not curable, the numbers are evidence people with the virus are living longer. People living with HIV can take antiviral medications and live just as long as people without the virus.
“Those living with HIV actually have gone up in a good way,” Halperin says. “People aren’t dying of AIDS.”
Halperin attributes a major part of the decline in new cases to the development of a preventative drug -— pre-exposure prophylaxis (PrEP) — approved by the Food and Drug Administration (FDA) in 2012. When taken consistently, PrEP can reduce the likelihood of contracting HIV by more than 90 percent, making it more effective at preventing the virus than condoms, according to the Centers for Disease Control and Prevention (CDC).
Vincenzo Pasquantonio, who heads City Hall’s equity office, says taking the preventative drug has changed the way he interacts with others. “What that has done is that has made us as people better people, because I’m no longer afraid of loving people and connecting with people,” he says.
“Those living with HIV actually have gone up in a good way. People aren’t dying of AIDS.” — Dr. Jason Halperin, a physician at New Orleans health clinic CrescentCare.
But only a small fraction of those who engage in behaviors that put them at a higher risk of contracting HIV are regularly using PrEP — also known by its brand name Truvada. A 2015 CDC report estimated 1.2 million people were at a high risk for contracting HIV, yet only around 77,000 used PrEP in 2016. That usage is nearly nine times what it was in 2012 — but still less than one-tenth of what experts say it should be.
Furthermore, disparities exist between the communities most likely to contract HIV and those on PrEP with the most disparity among blacks, people living in the South, young people and women. While more than half of new cases were diagnosed in the South in 2016, only 30 percent of PrEP users live in the South, according to AIDSVu, an online HIV mapping tool.
The racial disparities are even starker. Blacks living in Louisiana are more than six times more likely to be diagnosed with the virus than whites, according to a 2016 report by the Louisiana Department of Health (LDH).
Halperin says this represents a demographic shift in the populations most likely to contract HIV since the 1980s, when the public first became aware of the HIV epidemic.
“I think many people [think of] the white gay male in San Francisco, that kind of population that was at most risk over a decade ago,” he says. “We are not seeing that any more.”
Blacks accounted for nearly three-fourths of newly diagnosed cases in the state, despite making up less than a third of the state’s population. Pasquantonio says this racial imbalance constitutes an “emergency” in the city. “The house is on fire,” he says.
Mayor LaToya Cantrell established the equity office March 20, which will house the existing Human Relations Commission and LGBTQ+ Task Force.
This major gap exists even though studies show blacks are less likely to engage in behaviors that increase the likelihood of contracting HIV (unprotected sex, high number of sexual partners and drug use). Instead, systemic barriers tied to racism cause the discrepancy, the 2016 report says.
Those barriers include a lack of access to health care in general and inequitable treatment when they are able to access it.
“Just increasing insurance is not enough to ensure access in the African-American community,” Halperin says. “There is a long history of the medical system not being very welcoming to the African-American community.”
To combat some of those obstacles, Halperin says CrescentCare is committed to hiring black people in its facilities and has an advisory committee to critique racial biases existing in the organization.As a result, the clinic has increased the number of PrEP users at its facilities who are black to just under 25 percent — double the national rate.
But Halperin says it is “still appalling” to him how low that percentage is compared to the percentage of blacks at risk of contracting HIV in the city.
Young people also are disproportionately at risk of contracting HIV. Residents between the ages of 13 and 24 have made up one of the highest rates of new HIV diagnoses in the city in recent years, and rates are far higher for young black men. To lower these rates, Halperin says it’s important to look at avenues for HIV testing that exist outside the medical system, like testing in bars and at home parties.
PrEP — also known by its brand name Truvada — is statistically more effective at preventing HIV than even condom use, according to the Centers for Disease Control and Prevention.
Another reason for PrEP’s underuse is its $1,600-a-month price tag. However, between Truvada owner Gilead’s co-pay coupon cards and the state’s 2016 Medicaid expansion, there are several avenues to help make the medication more affordable for those who can’t shovel out the nearly $20,000 a year it costs out of pocket.
Medicaid covers the medication, doctor visits and lab work for the initial and subsequent HIV tests, which doctors recommend every three months after beginning PrEP. But Halperin says some insurance companies do not cover the full price of the lab work, which can cost up to $600 to $700 per HIV test and for which there are fewer payment assistance options.
“That’s a huge gap right now, and I’m not aware of any programs that are able to address that,” says Brandi Bowen, program director of the planning council.
Pasquantonio says when speaking to residents living with HIV, they mentioned the stigma long associated with the virus as one of their biggest hurdles. Studies show that bias and misperceptions about HIV can cause people not to get tested due to fear of testing positive or not to seek treatment once diagnosed. For black residents, the effects of stigmas associated with the LGBT and HIV communities are only compounded by existing racial stigmas.
“This isn’t like, ‘Oh, everybody get along, sing ‘Kumbaya’ and love one another,’” Pasquantonio says. “Stigma kills people. It’s had a very psychologically damaging effect on our residents — having this fear of others and this fear of people being a vector of disease.”
One effort to end the stigma associated with HIV is the Undetectable Equals Untransmittable (U=U) campaign, which the CDC endorsed in 2017. The campaign aims to raise public awareness of research showing that people living with HIV can take medication and maintain an undetectable viral load — meaning they have no risk of transmitting the virus to a sexual partner or to their children.
Louisiana Secretary of Health Rebekah Gee signed onto the campaign in March, along with Mayor LaToya Cantrell and Baton Rouge Mayor Sharon Weston Broome, making Louisiana the first southern state to do so, according to DeAnn Gruber, director of the health department’s Bureau for Infectious Diseases.
James Berman says making this information public will change lives. He remembers when he tried to enlist in the Navy in 1987 and was diagnosed with HIV. He was told he was unfit for service because he would be dead in two years. Now, 32 years later, he lives in Algiers with his wife and two children, all of whom are HIV negative.
“The one thing you thought you could never have — children — we now have,” Berman says. “It brings hope to a whole population that for decades hasn’t had any hope at all.”
Another component in decreasing new cases in the city is treating the virus as quickly as possible so it doesn’t spread. A CrescentCare initiative called Rapid Start guarantees the clinic will start newly diagnosed patients with HIV on medication within 72 hours, if not the same day.
Additionally, a drug called post-exposure prophylaxis (PEP) can be used in emergency situations and must be started within 72 hours of possible exposure to HIV.
But one potential new threat to progress is the opioid epidemic, which has caused a spike in HIV rates in other parts of the country. According to the United States Department of Health and Human Services (HHS), one of every 10 new HIV cases occur among people who inject drugs.
Halperin says since HIV is spread through sexual networks and needle-sharing networks, the populations most at risk for HIV and the populations most affected by the opioid crisis (who tend to be white and transient) have not yet overlapped in New Orleans.
“Interestingly, we have not seen the case rates increase in those who inject drugs,” he says. “I think it is inevitable that it will happen, and it will be very, very concerning when it does.” Expanding access to PrEP, HIV testing and clean needles through needle exchange programs is essential to preventing this overlap, he says.
The Washington Post reports that the Department of Justice (DOJ) is currently reviewing the national government’s part of the drug’s patent, which Gilead argues is invalid.
If the #BreakThePatent movement succeeds, it would pave the way for generic forms of the drug to become available in the U.S. — potentially lowering costs dramatically. In some countries, a one-month supply of the generic form costs around $6, 250 times less than Truvada costs domestically.
President Donald Trump’s 2020 budget proposal sought $291 million to “end the HIV epidemic” with a goal of decreasing new cases of HIV by 90 percent in 10 years. Meanwhile, the budget would drastically cut funding for global HIV programs by over $1 billion, earning it mixed reactions among HIV groups.
New Orleans is one of many cities that have joined the “Fast-Track Cities” initiative aimed at ending HIV by 2030 by getting 90 percent of people living with HIV diagnosed, on medication and virally suppressed so they have no chance of spreading the virus.
For those who have worked to lower HIV rates for decades, PrEP and the increase of programs at the local, state and federal levels make ending the epidemic seem within reach.
“For somebody who’s been working in this field for 30 years, certainly [I] never thought that we would be at this point,” Gruber, the health department official, says. “I think that our numbers are really starting to demonstrate the effectiveness of all of these things and everybody coming together.”