CROI 2017: A View from My Seat at the Table
April 24, 2017
Drug Use and MSM
Over the past few years, I have heard from friends in Oakland and Atlanta that there was an increasing problem with crystal meth use among Black MSM. I've had conversations with many of my colleagues about the increasing mention of PnP (Party and Play) on dating/hook-up app profiles. For years, the common assumption has been that meth is for white boys, but apparently more and more black men are going that route. There were a couple of posters about drug use and MSM that I totally expected to confirm that for me. The first, from CDC, looked at drug use by MSM in 20 cities across the United States. Surprisingly, they didn't see an increase in meth use. They saw an increase in prescription opioid use among Black MSM between 2008 and 2014. But just two steps away, the very next poster from George Washington University noted a drastic increase in crystal meth use among Black MSM in Washington, DC, over the same time period. I totally expect to see more research in this area.
Pre-Exposure Prophylaxis (PrEP)
What I heard coming from Seattle about pharmacist-managed PrEP was intriguing. Being able to avoid the cost of a clinic visit could greatly increase access and uptake. I contacted my agency's pharmacy partner when I got home to find out if they had the ability to order labs and prescribe Truvada for PrEP without patients having a clinic visit. (They can, and we will.)
And there was good news for women. Apparently, there was some confusion after all of the talk about good and bad bacteria in the vaginal microbiome at AIDS 2016. That was in relation to vaginal microbicides. Oral PrEP doesn't go through the vagina, so the vaginal microbiome has no effect on blood and tissue levels of the drug. Oral PrEP works for women. Period.
There were a few other abstracts dealing with community cohort care for adolescents, HIV testing incentives, and text messaging interventions for PrEP users that were interesting enough for me to mention to the folks at home, but if I'm being honest, I was looking for something else.
CROI 2017 was the first conference in an entire year where I didn't hear anything from the HPTN-073 team. Instead we heard from a team at Emory University, but what I heard only annoyed me. I don't need another study that tells me how Black MSM don't use PrEP. The study led by black men for black men (HPTN-073) showed us what works. Emory presented yet another study that showed us what doesn't work. They studied Black MSM aged 16 to 29 in Atlanta. Participants were offered risk reduction counseling, condoms and lube, and non-incentivized oral PrEP. After viewing a brief education video from WhatIsPrEP.org, the men who expressed interest were scheduled to see a study clinician to initiate PrEP.
The study results indicated that 56 percent of the men expressed interest but 39 percent of those never showed up for the initiation visit with the clinician. Of the ones that did come back, only 35 percent initiated PrEP. The study team's conclusion was that, "even after amelioration of structural barriers that can limit PrEP use," PrEP uptake was suboptimal. What structural barriers, you ask? Only lack of health insurance was addressed. (As if that's the most pressing structural barrier Black MSM face in the United States.) When I asked about what else was done to engage these men based on what we know from HPTN-073, I was told that there is really "no hard, a priori evidence that more aggressive interventions are needed" for Black MSM.
I sat down so that I wouldn't come off as the angry Black man, but when 79 percent of the participants in HPTN-073 accepted PrEP after a series of counseling sessions that combined service referral, linkage and follow-up strategies to address unmet psychosocial needs (part of what that team calls C4, or client-centered care coordination), I would argue that the need for more aggressive interventions is obvious. A study led by black men told us how to work with black men. Apparently, someone needs to fund more "For Us, By Us" studies so that we have a body of evidence showing what works because I'm tired of hearing what doesn't work.
There were no exciting results from large efficacy trials at this year's CROI like there have been for the last several years. It was back to basic science. That means the conference was even more boring than it normally is. But when I returned to Oakland and put my E.D. hat back on, I realized that I had the power to implement some of what I learned without waiting for studies to be published or government agencies to catch up to the science which could take years. I had the power.
In addition to client-centered care coordination and pharmacist-managed PrEP, we are in the process of adding an optional SMS intervention to the PrEP program at APEB, and we've started working with La Clinica de la Raza -- a local community-based organization that prioritizes Latino populations -- to support efforts to address the increasing HIV infection among Latino MSM. That's why I go to CROI. That's why I'm grateful to the scholarship committee for supporting my attendance and to AVAC for always providing what I need in order to stay on top of new developments in biomedical HIV prevention research. That's why I wish I wasn't the only African American man at those daily 7am breakfast meetings.
... cue Solange's "F.U.B.U."
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This article was provided by AVAC: Global Advocacy for HIV Prevention. It is a part of the publication The 24th Conference on Retroviruses and Opportunistic Infections. Visit AVAC's website to find out more about their activities and publications.
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