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Episode 2 Transcript

PrEP-ping for Atlanta Pride 2019

Erin Everett: Hey everybody. Welcome back to Exclusively Inclusive. I’m your host, Erin Everett and, hopefully, you were able to check out our first episode where we did a brief introduction, kind of let you know more about what the podcast is going to be about, and our intentions for the rest of the podcast. And just as a friendly reminder, this is very new for me. This is my first podcast and while I’m still seeing patients Tuesday through Friday, I do tend to be recording with you guys on Mondays, and so we’ll be checking that email fairly often, but it might take me some time to get back. And if there’s a lot of topic requests I might try, and kind of combine topics. So don’t expect a personalized response just yet, just in case I get flooded with emails. So just to give you a heads up, I’ll do my best, but just want to reset a healthy expectation there.

Erin Everett: Very excited to get going again with you guys. Hopefully, everybody had a good weekend. I know we’re supposed to be celebrating the start of fall and it doesn’t really feel like fall here in Atlanta. Hopefully, where my listeners are they’re getting some cooler weather. But yeah, it’s still ungodly hot here. Although, we were able to get out and Athens, Georgia celebrated their Pride festivities this weekend.

Erin Everett: Now, on Saturday the 28th they had Latin Festival, which my family and I just happened to stumble upon. We wanted to get out, try something different. And so, I’ve always wanted to check out Athens. It’s a cool, progressive town. And I hadn’t had the opportunity to visit yet. I’ve lived in Atlanta for 10 years and yeah, just hadn’t made the jaunt, which really isn’t that far. It only took us about an hour and 10 minutes. So it was a very easy drive.

Erin Everett: So on Saturday morning, I was talking to my husband and the kids and we all just decided, “Yeah, why not, let’s go check it out.” So we head to Athens and parked the car, we come out, first thing we see is Creature Comforts Brewery, which I tend to like their beer. And so we were going to go check that out, but we heard all this kind of commotion. And then we find out that it’s Latin Fest, which we could not have had a better time. Just to be able to walk around the streets. They had fruit from all the different countries in South and Central America. Any of the Latin American countries were there and represented. They had multiple performers for each one. So they were going through the list of countries and they had some sort of talent from each of those countries. So it was a great time.

Erin Everett: But while we were there, we noticed that there was an undertone of Pride theme there. There was a lot of different rainbows. People were wearing rainbow Pride flags, and celebrating Latin Pride, as well as LGBTQ Pride. And so, I actually found out that the 29th, which is the Sunday, was their actual Pride parade and festival. So, unfortunately, I didn’t get to attend that one, but I’m sure it was a great time.

Erin Everett: So, but all that to say Atlanta Pride is around the corner. And I know that the majority of cities celebrate earlier, there are quite a few that celebrate it later. And actually I found out that up until 2008 Atlanta used to celebrate in the month of Pride, however, they relocated it to October to line up with National Coming Out Day. So it was with good reason that they moved it to later in the year. And, hopefully, people are feeling empowered around Pride in Atlanta to come out to their family and friends, and have that safe space to go to.

Erin Everett: So with Pride comes lots of celebrations and opportunities to meet new people, so that brings me to my next topic, sexual health. So when people are getting together for Pride often it’s a great way to network, meet new people, and maybe have new hookups just to be blunt. So we really need to be thinking about our sexual health, and if you are someone who is eligible to get on TRUVADA for HIV prevention I highly recommend it. There are clinics in Atlanta that, if you are uninsured or under insured, do offer access to TRUVADA for PrEP. So it’s not just for the commercially insured. There are other places to get the medication.

Erin Everett: And TRUVADA protects against HIV transmission up to 98% in some reported studies so that’s when taken every single day. There are other ways to take PrEP mostly with our patients at Druid Hills Primary Care we really only endorse the use of PrEP daily because CDC has not backed the on-demand PrEP or the 2-1-1, as they’re calling it, where you can take it differently to daily dosing. However, the International Aids Society, and The Antiretroviral Society, do you say that it is effective in preventing HIV when taken on-demand. And you do lose a little bit of efficacy. I think it takes it down to about 96%, so it’s still quite a strong anti-HIV regimen, so something to consider.

Erin Everett: And so with PrEP comes three site testing as well, which we offer all of our patients. So if you’re coming in for a PrEP visit, or even if you’re not, but you want to get STD screened it’s so important to get screened in all three areas. And what that means is, for most people, we’re going to be doing throat swabs for gonorrhea and chlamydia, urine testing for gonorrhea, chlamydia, and sometimes trichomoniasis if you’re having sex with biological females and it makes sense to test for trichomoniasis.

Erin Everett: The other thing that we offer too is, if you’re a biological female we will offer a vaginal swab for gonorrhea and chlamydia and trich. And for anybody, male, female, however you identify, if you’re having anal sex we also highly recommend a rectal gonorrhea and chlamydia test. And all that entails is a tiny little cotton swab inserted gently into the anal area just for a couple seconds. And then, we take it out, send it off to the lab, and they let us know if there’s any gonorrhea and chlamydia in that area.

Erin Everett: The reason why it’s so important to be screening all of these areas is most of the cases of gonorrhea and chlamydia of the throat and the rectal tissue are completely asymptomatic. And when they do present symptoms they’re very vague, for a lot of people. Now, there are a cluster of people that will have rectal discharge, and that’s usually alarming enough to send them into their provider to get checked. However, some of the other symptoms are feeling like you need to have a bowel movement, but you can’t because the area down there is swollen, maybe a little bit of blood with the passage of stool, maybe a little bit of mucus, but often it doesn’t have any symptoms at all.

Erin Everett: The other more common symptom of gonorrhea and chlamydia infection is anal itching, which a lot of people experience due to other reasons like hemorrhoids or anal fissures, or just in general. And so they ignore it because they’re not aware that that could be an STD infection. So when you’re going out for Pride, which is just coming up in a couple of weeks it’s really important to get screened before and after having new encounters with people because gonorrhea and chlamydia is so prevalent in Atlanta.

Erin Everett: Now, the other STD that we need to talk about too is syphilis. A lot of people think, who aren’t in the community treating patients, that syphilis isn’t a big deal. It’s definitely a big deal. Syphilis has endemic rates here in Atlanta. And there are many other cities too, like New York that are experiencing very high rates of syphilis infections. It’s extremely contagious, guys. You don’t have to have penetrative intercourse to get syphilis. You can be snuggling someone who has a rash, you can be kissing, touching, having play, sharing toys, this, that and the other.

Erin Everett: Now, when you have primary syphilis you’re going to be experiencing things like a painless sore around your penis, or vagina, or anal area. And sometimes actually too in the mouth. And this sore, like I said, this usually doesn’t cause any pain or irritation. Most of the time when people notice it they do come in because hey, it’s a sore in their sensitive areas, so they want to know what the heck is going on. So they usually come in for that. However, if it is ignored it will go away, but it doesn’t mean that your syphilis went away.

Erin Everett: The other stage of syphilis is secondary where you get the rash on the hands and the feet. Sometimes it can just be the hands and the feet. Or sometimes it can be a full body rash. And it just looks like red blotches. It doesn’t usually itch or cause other symptoms. People sometimes, when they first have a syphilis infection, feel tired and lethargic, and might have a low-grade fever, but other people don’t have symptoms at all. And some people skip the two, obvious, stages of syphilis. Either they didn’t notice it occurring or they just presented differently and was not aware. So when that happens we can usually catch those infections on routine testing, which is another reason why it’s so important to come in for routine STD and testing.

Erin Everett: So a lot of people might be wondering, “Okay so I have syphilis, or I have gonorrhea, or I have chlamydia. How do I get treated?” Well, that’s really easy. First of all, we want to make sure that you don’t have a penicillin allergy because Bicillin, which is a form of penicillin is a preferred treatment for syphilis, especially for those people living with HIV. However, for those that do have an allergy, or in areas where Bicillin is not available, doxycycline is a very acceptable second line treatment. They’re both antibiotics, yes and antibiotics come with side effects, GI upset and things like that. However, syphilis cannot be left untreated. It has to be treated. We take it very seriously. Pretty much if anyone comes in my clinic and they have a valid concern about they may have been exposed. We’re not waiting for the blood test to come back. We’re going to test you for it and then we’re going to treat you for it too.

Erin Everett: And then we’re going to talk about PrEP because a lot of patients, who if you’re not already on it, a lot of patients who are diagnosed with HIV also have syphilis at the same time, and so it’s a dual diagnosis. And so it’s very important, if you were able to contract syphilis and you did not contract HIV, and you’re not on PrEP, then we would need to revisit the PrEP issue because you’re engaging in behaviors that put you at risk for contracting HIV.

Erin Everett: The other thing is with gonorrhea and chlamydia there are a couple of different regimens, depending on the site of the infection, but most of the time it’s just a quick shot in the office, in the arm, not of Bicillin but of Rocephin. And then, depending on the side of the infection, we alternate between two other complementary antibiotics. When I say complementary, they complement the shot, they are to be given together. This helps reduce the risk of gonorrhea and chlamydia becoming resistant to antibiotic therapy. So it’s super important.

Erin Everett: I often get patients from other areas, or other clinics, however, if they’re coming from other out of states, I’ve definitely got a lot of patients that come to me for transgender medicine across state lines, and find out that they have been inadequately treated for their gonorrhea, chlamydia or syphilis infection. So, again, it’s really important that you go to a provider that you’re comfortable talking to, and that you know that they’re well versed in STD treatment, and prevention. And that, again, I’m going to say it one more time that you’re comfortable talking about your sexual habits and behaviors with, because I always tell my patients it’s kind of a joke, but not really. There are two people you should never lie to, your healthcare provider and your lawyer because if you’re not telling me the truth, then I can truly help you. But it is my job to give you the tools you need to be safe, and healthy and be able to explore a very happy, healthy sex life. But preventing yourself from getting these STDs and STIs should not have an negative impact on that.

Erin Everett: So we’ll probably have an entire talk about PrEP, but it is really important before Pride that we talk about it even more because last year at Pride the clinics in Atlanta, AIDS Healthcare Foundation, Positive Impact, they were doing free onsite testing for HIV at Pride. And then connecting people with providers to take care of them should their test come back positive. However, we don’t want any positives at Pride. We definitely want to capture those that are HIV positive and unaware, or have not been connected to healthcare providers. But the goal is to try, and reduce, and eliminate HIV infection by putting those who are at risk for getting HIV on prevention treatment. And those that are already living with HIV, keeping them on the antiretrovirals, keeping them undetectable because a statement was released that if you are undetectable you are untransmittable. There are certain situations where that’s not true because people can blip up on their viral loads, but typically that’s not a healthy virus. It’s going to be easy for people to transmit. However, we still encourage the use of HIV prevention for anybody who’s engaging in any kind of high risk behaviors.

Erin Everett: So what are high risk behaviors? Basically, men who have sex with men are classified as having higher risk behaviors because the majority engage in anal sex. And then, any biological female engaging in receptive anal or vaginal sex, any IV drug users, those are all considered high risk. IV drug use is one that doesn’t get talked about enough because a lot of people are engaging in IV drug use, but aren’t mentioning it to their providers, and therefore aren’t getting on PrEP. If you’ve had an STD in the last six months, if you have more than one sexual partner, if you do not use barrier methods of protection, and sometimes even if you do it’s like wearing your seatbelt even though you have airbags. I coined that one from one of my very dear colleagues, and we just want to be extra safe.

Erin Everett: So when taken daily, like I said earlier, PrEP protects against HIV 98% of the time, and it’s a drug called TRUVADA. TRUVADA’s been around for a very long time as part of HIV treatment. And so it does have some side effects. And, recently, I’ve had some patients coming to me and asking me about some commercials they’ve seen for class action suit on TRUVADA. I’m not going to talk too much about the lawsuit, but what the side effects they’re talking about are the risk of kidney damage and bone mineral density loss.

Erin Everett: So first we’ll start with kidney damage. I have been prescribing TRUVADA for PrEP since 2015, and I think I’ve only had to take off one or two people for kidney function issues. And with those patients they had comorbidities. Comorbidities is a fancy word for saying they had other medical issues. It wasn’t just a healthy individual coming in, and then having to take them off PrEP because their kidneys weren’t happy. While that’s possible, it’s not the common scenario. And so when you’re on TRUVADA for PrEP, we check you every three months. That means we check your kidney, liver function. We’re offering that three site testing, I just went over, we’re doing syphilis testing and we’re doing a repeat HIV test every three months.

Erin Everett: And so we’re going to be able to see subtle changes in your kidney function. So I really try, and reassure my patients and let them know, don’t worry about your kidneys, I’ll worry about your kidneys. You stay hydrated. Don’t take too many nonsteroidal anti-inflammatories like ibuprofen, ALEVE. You really shouldn’t take too many of those anyways. And if something happens you just let me know but, otherwise, we’ll be checking on you every three months.

Erin Everett: So the bone mineral loss. Part of the way … and I’m not a pharmacist, but from my understanding with TRUVADA, part of the way that it works is to insert itself in the plasma it does take out some of the calcium in the plasma. And so that can take away calcium from your bones. And in patients living with HIV this is a much more tremendous effect, especially because there are certain mechanisms of HIV that already increase bone mineral loss. And so that lumped on top of a drug that’s a separate concern. And it’s not to diminish that, but we’re talking about, right now HIV negative patients, people who are not living with HIV. So some of the studies released did show slight decreases in bone mineral density when on TRUVADA for prevention long-term. However, once the drug was discontinued, those levels returned to normal.

Erin Everett: So, I don’t have anybody who’s on TRUVADA for PrEP who has … going to be on it for 15, 20 years. However, that’s always possible, but they are releasing a new drug in the fall, and it has been approved in some areas. And I actually have a couple patients on it already for different situations, but until we get the official go ahead on it, it’s not being like first-line prescribed yet. So that drug’s called Descovy and it’s more mild on the kidneys, and it’s doesn’t have the bone loss. So that won’t be a concern for patients.

Erin Everett: Now, the biggest side effect of TRUVADA, once you start taking it, the most common I should say is a little bit of GI upset, nausea, vomiting and increase in bowel movements. That’s the one I counsel on the most. It’s, usually, transient and goes away within a few days to a few weeks. Never usually persists past the four week period. If it does and it’s cumbersome, then we reevaluate. Mild headache, if you get a rash or something like that, that is a sign of an allergic reaction. We would need to talk about that.

Erin Everett: But TRUVADA is very well covered by all commercial plans. I mean, very rarely do we come across a plan that has given us a hard time paying for TRUVADA anymore. It’s well covered. It comes with a co-pay card that enables people to, once they go to their pharmacy, they bill TRUVADA. And the pharmacist might tell them, “You have a $200 co-pay on this.” Well, that is when the Gilead co-pay assistance card comes into play. And it has a certain amount of money on there that patients can use towards the cost of TRUVADA. That’s also true for HIV medicines. And so most of my patients are getting it free or very cheap.

Erin Everett: Now, are those that don’t have insurance or are under insured, there are several clinics in the Atlanta area that are able to give them access to TRUVADA on a more limited supply, of course, because it has to do with funding. But Gilead itself will also pay for people to be on TRUVADA for about 90 days, if they’re in between healthcare coverage. So there’s always a solution to a problem, but we don’t know about a problem until we have the conversation. So, again, if you have a healthcare provider that you do not feel comfortable discussing any of this with then it’s time to find a new healthcare provider. Feel free to email, I can give you resources. But there’s a lot of great healthcare providers and LGBTQ providers in the area. Of course, you can come establish care with me at Druid Hills Primary Care. I do see new patients, so anybody’s welcome to come on board and get signed up. And I’ll sit down with you one-on-one and go through all of this with you. But if you have any specific questions or want more information, again, that email erin@exclusivelyinclusivepodcast.com.

Erin Everett: Okay, well I think this is where I’m going to leave it. We have a lot of topics to talk about. And just to remind you guys, those of you who are listening, I do plan on having several different special guests coming in and talking about themselves, and what they do for the community, and what they have to offer. And that’s going to be ranging from, like I said, my collaborating physician will come in here, Dr. Joe Smiddy. I’ll also have some therapists that I work with and refer patients to come in and talk to you. And it’s not just about transgender medicine, but that is the highlight. But they’ll be talking to you about all kinds of different things. We also have some local urologists who specialize in transgender medicine, hormone replacement for transgender individuals, and also testosterone replacement therapy for cis men, or biological men who just have hypogonadism.

Erin Everett: So there’s a lot of different resources we’re going to be utilizing, and so I want to make sure I don’t make these episodes too long so that you lose interest. It was a great time recording with you guys today, and I’ll see you guys next week. Stay safe.