San Francisco Chronicle - (Sunday)
Push for sexually active to get back on anti-HIV drugs
Year after year, San Francisco has seen the number of new HIV diagnoses fall, with the stated goal of becoming the first jurisdiction in the United States to reach zero new infections. Part of the progress — down to 166 diagnoses in 2019 — is owed to pre-exposure prophylaxis, a set of drugs commonly known as PrEP, which must be taken with some regularity when an individual is sexually active.
During the height of the pandemic, however, when people were sticking close to home, many LGBTQ patients fell off the daily pill and new enrollments dropped considerably.
Now, with bars open and dating apps seeing a crush of new users, local health authorities have been pushing to get patients back onto PrEP and into clinics for testing to make sure that one pub
lic health crisis doesn’t lead to another.
“We think the COVID-19 pandemic certainly will set us back — it set us back in so many ways,” said Dr. Stephanie Cohen, the medical director of San Francisco City Clinic. “But I still think we can (get to zero), and in many ways we learned lessons from COVID-19 that I think we’ll be able to apply to getting to zero.”
For a sense of scale, City Clinic had 742 new enrollments in 2019 and 519 in 2020, a 30% decline. Magnet, a Castro sexual health clinic, saw about a quarter of current patients drop off of their regimens during the height of the pandemic, according to director Jorge Roman, while new enrollments fell by more than 50%.
Meanwhile, Dr. Brad Hare with Kaiser Permanente said 70% to 80% of the hospital system’s 3,000 San Francisco PrEP users stopped taking the drug when the city ordered residents to shelter in place, though those numbers have since rebounded.
Pre-exposure prophylaxis — which include the drugs Truvada, its generic counterparts and Descovy — are all incredibly effective at preventing HIV/ AIDS infection. Studies show that consistent, daily usage leads to a 99% reduction in risk. But to access the drugs, patients are generally required to submit to quarterly HIV and other testing for sexually transmitted infections.
To make sure patients didn’t fall off their regimens entirely, health care providers in San Francisco tried a number of tactics.
At both Magnet and City Clinic, physicians made the call to relax the quarterly testing requirement. They also made STI testing safer, by either offering take-home tests or allowing patients to collect samples themselves during their visit. Magnet also started a public information campaign across social media platforms, including Facebook and Instagram, to remind patients they were open.
“We recognize that people are out there hooking up and needing testing and needing services, so we wanted to make a conscious effort to remind people that our doors haven’t closed,” Roman said. “We’re here, we’re ready and we’re open for business.”
Kaiser switched to “a 100% virtual PrEP” for new starts and for follow-up questions. Workers also spoke with patients who take Truvada about an alternative, more spontaneous dosing regimen called 2-1-1, in which a patient takes two pills two to 24 hours before intercourse, one pill 24 hours later and another 24 hours after that.
When San Francisco resident Noel Morales, 31, realized he wasn’t going to be “meeting anyone or seeing anyone for a while,” he spoke with his Kaiser health care provider who talked to him about the 2-1-1 method in case something were to come up. Last fall, when he decided to take tentative steps back into the dating scene, he simply switched back to daily usage, before promptly meeting his now-boyfriend.
Many of his friends had similar experiences, he said, and much of that was because of easy access to PrEP providers, something San Francisco has been pushing hard for years now.
By most measures, the efforts have been successful. City Clinic and Magnet are both nearing their pre-pandemic new enrollment numbers, and Hare said Kaiser has more patients enrolled on PrEP now than it did before the pandemic.
It’s also possible some of the stragglers will come back in the next few months. Some patients who stopped during the pandemic probably have stockpiles of the drugs in their medicine cabinets — Morales said this was true of a few of his friends — that they’re only now starting to work through.
That’s one of the many challenges of tracking the usage of a daily pill that, unlike other medications, can be stopped and started at will. “It’s always difficult to really figure out who fell off that shouldn’t have,” Cohen said. Some may have met a partner or taken some time away from dating, while others may have lost insurance or had issues at the pharmacy.
“Things that should have happened in a perfect system didn’t happen because of the pandemic,” Cohen said. “We just want to (get the) system ... back to being as as low-barrier as possible.”