A 22-year-old former patient of mine texted me on the morning of March 10, 2020. He is a sexually active Black same-gender-loving (SGL) man. He used to be on pre-exposure prophylaxis, or PrEP, but is not currently. He resides in Atlanta.
He had a sexual encounter in Miami on March 9, a little over 24 hours before he texted me, with another man where he was the top, but he didn’t use a condom. He didn’t know this man’s HIV status, and couldn’t track him down, but was concerned about potential exposure to HIV and what he could do to prevent it. He asked about post-exposure prophylaxis (PEP).
Because I am on a leave of absence from my primary job and in New York with family, I couldn’t see him personally. I referred him to AID Atlanta (which is affiliated with AIDS Healthcare Foundation [AHF]) and their medical clinic, after first calling to confirm they would see walk-ins for PEP. Since he was within the 72-hour recommended window period to receive PEP, I was told by a kind receptionist that they could see him.
He let me know he was heading there. Two hours later, he texted me again:
“Here, and they are saying since it was a one-time encounter and I’m not sure of his status, they would rather not give me PEP. Because the likelihood of me contracting it [HIV] is low.”
I encouraged this young man to fight. I told him that this was his decision, not theirs, and that while topping is less risky than receptive anal or vaginal sex, it still carries risk. And the fact that he doesn’t know the HIV status of this man was even more reason to get PEP.
“He [the nurse practitioner (NP)] is not going to do it. Starting labs for PrEP now,” he responded.
So the NP felt it was not urgent enough for PEP but was comfortable with just prescribing PrEP. I offered to call in the PEP prescription for him. He declined.
“No, you don’t have to do that. I’m just over it at this point. I spoke with the director, and he apologized,” he said. I was encouraged that he had advocated for himself with the director.
“Did the director agree with you?” I asked.
“No,” he responded. “He agreed with the provider, according to their protocol. And he said since I topped and it was only one time, I ‘should’ be fine.”
Texting this young man at that moment, I’m wasn’t sure what “protocol” tells clinicians and a medical director to downplay an obviously risky scenario and dissuade a patient from taking PEP. Particularly when the patient is concerned, intelligent, and seeking options to ensure his sexual health.
I told him to file a complaint and speak to an office manager. I also told him that his sexual health is his call and this encounter would be considered an indication for PEP—but this former patient of mine was now discouraged.
“I’ll just take his word, if it’s this much of a hassle, and pray I don’t contract anything,” he responded. “I wasn’t upset about him following protocol. I just felt devalued as a person.”
I told him I was sorry. No one seeking medical care should leave feeling devalued as a person. I was 1,000 miles away and felt utterly powerless.
“I just opened up to you [the NP] and told you my story, and you can’t even look me in the face or acknowledge what I’m going through,” he continued. “Everyone else there was warm and hospitable. It was just him. Similar to the last incident I had.”
I remembered he had gone through a comparable experience trying to get PrEP before he saw me. Another clinician tried to talk him out of utilizing PrEP as an HIV-prevention option, despite his history with condomless sex warranting it.
I was at a loss for words.
“He [the NP] told me, ‘Oh, if you would have told me that there was a condom involved and it broke, then I would have readily prescribed the medication.’”
He then texted me as if speaking to the NP: “So, you’re telling me that I should have lied and just said the condom broke?”
Medical facilities and staff are charged with overseeing our community’s sexual health, not with basing their clinical decisions on personal beliefs and moral judgments. Making patients feel “devalued as a person” during a clinical encounter and leaving them resorting to praying as an HIV prevention option is inexcusable. Especially when we have the science to intervene.
He ended by telling me that this sexual encounter 24 hours ago was under the influence of alcohol, his phone was stolen, and he felt he was given substances by this man. I asked him if he told the NP that.
“I didn’t get a chance to explain all of it, because we started arguing, but I did tell him I was out of my mind, my phone was stolen the same night, and that drugs and substances were involved,” he said. “The guy was snorting coke and making me inhale the poppers, or whatever that stuff is.”
I kept offering to call a PEP script in for him, but he was over it. Physically and emotionally.
As an internal medicine doctor, public health advocate, and sexual health provider, hearing this encounter made me sick to my stomach. Yet these stories are a dime a dozen, and they have to stop.
I recalled another young Black gay male in Atlanta who went to AHF/AID Atlanta in October 2019—HIV positive, who had a positive syphilis titer with neurological and eye symptoms (clear indications for a spinal tap and/or ophthalmologic referral)—and was sent home after receiving one penicillin shot for what they called secondary syphilis. Even when he showed them the Centers for Disease Control and Prevention guidelines on when to evaluate patients for neurosyphilis, he was shot down and sent home. A few weeks later, when his symptoms didn’t improve, he ended up with ocular syphilis and needed to be treated with intravenous penicillin at Grady Hospital for two weeks.
HIV and other sexual health centers in Atlanta are supposed to be helping reduce the burden of HIV. If you offer PEP services, and someone comes to you for PEP after a condomless sexual encounter and is a member of the subpopulation with the highest rates of HIV in the country, you are supposed to help them, not turn them away or offer PrEP when PEP is clearly indicated. I don’t know of any protocol that states that PEP is only for “bottoms”—but no clinician should be so nonchalant with a patient who shows up within the window period for PEP and meets “risk” criteria. Particularly when you consider that patients often don’t tell us the full details of their sexual encounters due to fear of judgment and shaming—which is exactly what happened, and made this whole situation a self-fulfilling prophecy.
And then we wonder why Black gay men (and other populations) don’t access clinical services for sexual health.
Change the protocol. Change the attitude.
I posted his story on Facebook at 4:10 p.m. After further harassing my former patient, he finally agreed to let me call in a PEP prescription to the local Walgreens community pharmacy in Atlanta. That was at 5:15 p.m. He texted me a pic of the pill bottle in hand before 6 p.m. Clinical leadership at AHF/AID Atlanta found out about his situation within hours of my post. The provider called the patient and apologized before 7 p.m., offered him the PEP, and even followed up with him by phone a couple of days later. They have arranged to have him follow up there in a month for repeat lab work and likely re-initiation of PrEP.
I also fielded calls from people who were disappointed in me and expressed that they wouldn’t have “expected” me to put AHF/AID Atlanta on blast on social media like I did. Some said there were “better,” more “appropriate” and “proper” ways to bring attention to this issue. Others were concerned that telling this young man’s story on social media would just delay an investigation of the issue. Obviously, it didn’t.
I was disappointed as well. Disappointed in how these same people were more concerned at the stylistic approach of my bringing this matter to the forefront than they were about what actually happened to this young man.
In hindsight, would I do it again? You bet I would.
This isn’t about putting AHF/AID Atlanta or any other clinical facility “on blast.” It’s about holding the medical systems and personnel accountable. I’ve held my tongue in the past when hearing about situations like this happening to my patients, friends, family, and community members seeking sexual health and HIV/STI care. I’ve followed “proper” protocol and used vague terms on social media and emails instead of calling out specific institutions for mistreating Black queer folk. The response often includes a light slap on the wrist, no formal apology to the patient(s), no institutional or system changes, and a good amount of blaming the patients themselves.
I regret holding my tongue on those previous occasions and following what others deemed an “appropriate” response to medical discrimination. When this latest situation was brought to my attention, I reached my boiling point. I had already lost my faith in “proper” channels to address institutional mistreatment of Black gay men (and other vulnerable populations). AHF/AID Atlanta and other facilities are HIV specialty clinics, where you wouldn’t expect patients to encounter this level of conscious and implicit bias. But they do, and many others will, until we demand that they provide the competent care that our communities deserve.
This is why I’m not overly optimistic about the Ending the HIV Epidemic initiatives that have been rolling out in Atlanta and other areas of the United States. With judgmental clinicians who prioritize personal bias over proper protocols, we won’t ever see a reduction in new HIV infections. Not because we don’t have the science at our fingertips, but because our social graces lag woefully behind medical advances. I can’t speak to what was in that NP’s heart who evaluated my former patient. All I know is that my former patient left that experience feeling devalued as a human being, at a time when he was feeling most vulnerable. That is not OK.
On a beautiful spring day in 1996, I took an oath to “Do no harm” to patients under my care. This also extends to witnessing indiscretions perpetrated against patients by my colleagues in the medical profession. They should hold me to the same standard. My loyalty is to my patients, not to corporations or institutions.
Black same-gender-loving men are gold. Black cisgender and transgender women and men are gold. Black people are gold. This is about life, death, and the future of our communities. We deserve better.