HIV PrEP

bucket

By Erika Sullivan, MD

We are entering an era where the scourge of HIV/AIDS seems surmountable. Herculean efforts in the fields of infectious disease, immunology and care delivery have made HIV/AIDS a chronic disease, at least here in the United States. To a degree, this represents a fundamental switch for many patients, especially those in the MSM/LGBTQ community (men who have sex with men, and lesbian, gay, bisexual, transgender, queer) who had grown accustomed to the vigilance that is required to prevent HIV transmission. There is, however, a growing trend amongst young people, both in and out of the LGBTQ community, who have not grown up in the shadow of HIV/AIDS. This group is experimenting with sexual practices that put them at higher risk for all sexually transmitted infections (STIs), not just HIV. A recent World Health Organization report indicates that there has been a worldwide resurgence of multi-drug resistant gonorrhea, which may be due, in part, to higher rates of unprotected oral sex.

How did it come to this? How is it that young people (and others) are feeling so sexually invincible that they will engage in higher-risk behaviors which may expose them to HIV and other STIs? The answer to this question may lie in a story I heard when I was in graduate school. It was told to me by one of my tropical medicine professors, and it may be apocryphal, but it is a compelling anecdote for how disease epidemiology interacts with culture. Robert Desowitz, a professor of tropical medicine (and author of one of my favorite books “New Guinea Tapeworms and Jewish Grandmothers”) was at a dinner with an anthropologist, and the conversation turned to the anthropologist’s recent endeavor, which was mapping a series of ancient villages in West Africa. The oldest village was closest to the nearby river, but evidence suggested that at some point the village had been abandoned, in favor of a village on higher ground, but farther away from the river. The pattern then repeated itself, the second village seemed to have been abruptly abandoned for a newer village down by the river, and on and on it went, in a zig-zag pattern close to, and then alternately far away from, the river. Dr. Desowitz asked for the location of the river, and when supplied with a map, he proposed that the movement of the villagers was due to something called African River Blindness, or onchocerciasis. This is a parasitic infection that is spread by the black fly, which causes a variety of illnesses, but blindness is the chief among them.

Dr. Desowitz hypothesized that the oldest village likely experienced a heavy burden of disease, causing many of the adults to go blind. Correctly thinking that the proximity to the river had something to do with the increased incidence and prevalence of blindness, the villagers decided to move to higher ground (outside of the range of the black fly that transmits the parasite). Generations would pass, young people would forget the collective wisdom of why the village was far from the river, and would lament having to trudge up and down to the river to get water every day. At some point, the prevailing wisdom of living so far from (or close to) the river would shift, and the villagers would relocate to the lower/higher ground, and the process would repeat itself.

When I signed on to be a family doctor, I hadn’t really appreciated the role I would have in community and institutional memory: “Do this because X, Y or Z. Yes, you may not have this disease or be at risk for that disease, but it is my job to remember that you are at considerable risk for it, and to help you mitigate that risk as much as possible”.

Our clinic recently started providing HIV pre-exposure prophylaxis or PrEP in a primary care setting. This is a new clinical service that has been a longtime in the making, but in retrospect, has been long overdue. Understanding the risks that patients take, educating them about these risks, and intervening when possible to reduce those risks is a large part of what I do as a family doctor. It seems to me, that with respect to HIV/AIDS (and vaccines and obesity and…many things!) we are standing on the high ground right now, far away from the river’s edge and increasingly immune to, or at least unaware of, the inherent risk in living down by the water. It would be easy and understandable to question why it is that we live so far from the water. I’m proud of my patients who understand their risks when it comes to sexual practices and HIV/AIDS and are doing everything they can to decrease these risks, even if it means lugging water back and forth to the river each day. For those who do not “remember”, I feel empowered to educate them about their risk, and, for lack of a better metaphor, to provide them a bucket. An interesting observation that has been seen in some of the studies where HIV PrEP was initially developed have shown an increase in other STIs, but NOT HIV, in individuals taking PrEP. The theory being that if patients feel like their efforts protect themselves from HIV give them license to engage in practices which may put them at risk for other infections. As we learn more about HIV PrEP, we will have to study the outcomes to make sure that we don’t simultaneously provide our patients with water buckets while leaving them blind.

Sullivan

Erika Sullivan, MD is an Assistant Professor (Clinical) in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

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