Monthly Archives: February 2012

Policy Focus: PrEP Could Be A “Game Changer” in Fight Against HIV

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Analysis examines biomedical prevention technology to be reviewed by U.S. Food and Drug Administration by June 15, 2012

Pre-exposure chemoprophylaxis (PrEP)—taking antiretroviral medications to prevent HIV transmission—could be a “game changer” for HIV prevention. PrEP has demonstrated partial efficacy with men who have sex with men (MSM), transgender women, and heterosexuals in several recent studies. Recent modeling of PrEP implementation coupled with scaled up treatment predicts that PrEP could significantly reduce HIV incidence and prevalence. And if PrEP is accompanied by sustained care, behavioral interventions, and safety monitoring, PrEP need not lead to increased sexual risk behavior or drug resistance.

The latest Policy Focus from The Fenway Insitute summarizes the state of PrEP and microbicides research as of January 2012, looks at willingness to use PrEP among various populations, addresses concerns about PrEP that could present obstacles to implementation, offers strategies for effective implementation, and examines policy issues related to cost and how to make PrEP accessible to those most vulnerable to HIV.

The Fenway Institute’s analysis found that the most effective prevention interventions will be those that combine behavioral interventions, structural interventions, and emerging biomedical technologies, such as PrEP and microbicides. The analysis concludes with recommendations for implementation of PrEP, including:

  • If the U.S. Food and Drug Administration (FDA), which is considering approving FTC-TDF for use as PrEP, feels that research on PrEP’s efficacy among heterosexuals is inconclusive, it should consider approving PrEP for MSM now separately and consider heterosexuals, IDUs and other populations in the near future as the science advances;
  • The World Health Organization (WHO) should issue guidance on PrEP that takes into account the promising results of the iPrEx study, Partners PrEP, and the Botswana CDC study;
  • Following the release of the Bangkok injection drug user (IDU) trial results, if appropriate the U.S. Centers for Disease Control and Prevention, the U.S. Public Health Service, and the WHO should issue guidance for PrEP with IDUs.;
  • States should provide access to PrEP as a critical prevention service and prescription medication under the Essential Health Benefits provision of the Affordable Care Act;
  • State Medicaid programs should also cover PrEP as a cost-saving measure that will improve public health and ultimately save money in health care costs;
  • Provision of PrEP to MSM and transgender women should occur in a broader context of ensuring clinically competent health care to gay, lesbian, bisexual and transgender people.
You can read or download the full PDF document below or on The Fenway Institute’s website.

You can also read past Policy Focuses on asking about sexual orientation and gender identity in clinical settings. 

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HIV and MSM Abroad: The Fenway Institute’s Work in Malawi

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malawifigure5

In December of 2011, staff from The Fenway Institute collaborated with Johns Hopkins School of Public Health and the Centre for the Development for People to train Health Care Workers and Peer Educators in Malawi on working with MSM and preventing HIV in this vulnerable population. Fenway Health’s Medical Director of Behavioral Health, Kevin Kapila, shares his experience.

When I first learned about the possibility of conducting trainings for medical providers in Malawi, like many Americans I did not know much about this landlocked country in southeast Africa. I knew, like most gay men, that Madonna had adopted a child from Malawi, and was also aware of the gay couple that was sentenced to 14 years hard labor for having an engagement ceremony.

I did some research and found out that Malawi faces a lot of challenges—it is the second poorest country in the world, 11% of its population is infected with HIV, and over 50,000 people a year in Malawi die from HIV/AIDS. Malawi is also known as the “warm heart of Africa,” because of the kindness of its people, which from our experience there is most definitely true.

A view from the car on trip from Lilongwe to Blantyre

The Fenway Institute was invited to take part in trainings in Malawi that took place in early December of 2011. The trainings focused on educating health care workers and peer educators to meet the needs of men who have sex with men (MSM) and help prevent HIV in this vulnerable population. As one of Fenway Health’s medical providers, I was honored to be part of these trainings that will hopefully create positive change for Malawi’s MSM. The trainings were done in collaboration with Johns Hopkins School of Public Health and The Centre for the Development of People (this is a human rights organization focused on the needs of the LGBT community in Malawi.) The trip was funded by a grant from AmFAR. The team from Fenway included Rodney VanDerwarker, MPH (Administrative Director of The Fenway Institute); Marcy Gelman NP,MPH (Associate Director for Clinical Research); and Kevin Kapila, MD (Medical Director of Behavioral Health and primary care provider.)

Preparation for these trainings started months in advance, with multiple conference calls with Johns Hopkins and our colleagues in Malawi. We were able to put together a two-day training program for health care providers and a one-day training for peer educators. There were many challenges that had to be overcome, including the lack of resources and many negative perceptions about men who have sex with men.

The team meets in Lilongwe after two long days of travel

We left Boston and after almost two days of travel landed in Lilongwe, the capital of Malawi. We met Stefan Baral from Johns Hopkins and Gift Trapence from CEDEP and began the five-hour drive from Lilongwe to Blantyre. This was not an easy drive on this two-lane highway that was populated by cars, bikes, pedestrians and goats. The trip did allow us to appreciate the beauty of the country and connect with each other and discuss the upcoming trainings.

The first day of the trainings was attended by over 20 representatives from different health service providers in Malawi. Stefan Baral presented on human rights and epidemiology. Rodney VanDerwarker talked about the Fenway Health model of care. Marcy Gelman gave a presentation on how to take a sexual history from MSM, which was followed by role-playing exercises. Marcy had a difficult challenge, as this was is the first time many of the providers had been exposed to some of this information in a culture where gay and bisexual men are not accepted. We were prepared for the possibility this would not go over well, but Marcy’s extensive preparation in regards to the cultural issues, well thought out presentation, and stellar execution of the material went over very well. There was active participation from the audience and the first day ended well.

Marcy and Rodney preparing on Day One.

Marcy started the second day of training with continued education on identifying, screening, and treating the different sexually transmitted infection that commonly occur in MSM. I was the presenter for the second half of the morning and the afternoon sessions, and started with going over the use of condoms and lubricants, which are in short supply in Malawi. 

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National Black HIV/AIDS Awareness Day

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HIV/AIDS disproportionately affects the black community, including black men who have sex with men (MSM) and transgender individuals.

February 7, 2012 is National Black HIV/AIDS Awareness Day. In its twelfth year, NBHAAD highlights the disproportionate impact HIV/AIDS has on the black community and four areas through which positive change can be achieved: education, testing, involvement, and treatment.

This conversation is as vital today as it was on the first National Black HIV/AIDS Awareness Day over a decade ago. According to the Centers for Disease Control and Prevention (CDC):

  • African Americans are the racial/ethnic group most affected by HIV.
  • In 2009, African Americans comprised 14% of the US population but accounted for 44% of all new HIV infections.
  • An estimated 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV  in their lifetimes.

HIV/AIDS awareness, testing, and treatment are especially important to men who have sex with men (MSM) and transgender individuals of color. The CDC states:

In 2009, black men who have sex with men (MSM) represented an estimated 73% of new infections among all black men, and 37% among all MSM. More new HIV infections occurred among young black MSM (aged 13–29) than any other age and racial group of MSM. In addition, new HIV infections among young black MSM increased by 48% from 2006–2009.

And the National Transgender Discrimination Survey reports an astoundingly high rate of HIV infection among black transgender respondents (25% compared to 2.4% in the African American general population). Data from CDC-funded HIV testing programs show that in 2009, the rate of new HIV infections among transgender persons was 2.6% compared to 0.9% for cisgender males and .03% for cisgender females.

The percentage of newly identified HIV infections was highest among black transgender individuals at 4.4%.

In 2009, African Americans represented only 14% of the US population but made up 44% of all new HIV infections.

Changing the reality of HIV/AIDS in black communities will take more than a day; but NBHAAD is an opportunity for us all to educate ourselves and others as well as recommit to our own health (practice safer sex, get tested, seek treatment!) and encourage others to do the same. It is also an opportunity to contact your elected officials to tell them that you support HIV/AIDS funding and other programs that reduce health inequity for people of color, the LGBT community, and low-income families and individuals.

For more information on HIV/AIDS in the black community—in addition to the resources linked above—visit the Black AIDS Institute’s website. Not only do they have fantastic suggestions for NBHAAD actions, their publications contain a wealth of information on this important topic.

And if you’re in the Boston area and would like to get tested, Fenway: Sixteen offers walk-in hours Mondays, Tuesdays, and Thursdays. Testing is also available in Jamaica Plain through our partners at the Multicultural AIDS Coalition (MAC). And if you’ve already been tested recently, be sure to share these resources with friends. 

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