Our failure to promote PrEP to at risk patients

The medical profession has failed in the area of preventative healthcare yet again. We have failed in an area which makes us “uncomfortable” when we discuss it with patients. That area is sexual health, and disease prevention. We fail because we are “uncomfortable”. We are failing to prevent a disease with the power to kill, when we have had some tools to prevent it for years. I am talking about HIV. Perhaps most shamefully of all, we are failing to use a powerful new tool in our therapeutic arsenal to prevent HIV transmission.

It is most certainly true that we understand a great deal about the HIV virus’ biology, and we have used that knowledge to create treatments that prolong the lives of HIV positive individuals. Perhaps most importantly, these drugs provide good quality of life. Now, we have found that these same drugs used for treatment of HIV infection can be used to prevent infection in the first place (a strategy called Pre-exposure prophylaxis, or PrEP). To me, this is almost a no brainer. There is one hang up however: the possibility of promoting resistance to antiviral drugs.

Consider the fact that patients are notoriously bad at taking medications as prescribed. All medicines. Not just antivirals. Physicians have already raised a new generation of super-bacteria by overusing antibiotics. A problem which is only compounded by the fact that many patients never finish the prescribed course. Individuals, regardless of HIV status, are bad at taking medicine as directed. So when HIV positive individuals don’t take their medications quite like they should, that is already a situation that can promote resistance. I contend that providing patients with PrEP is not going to make the problem of emerging resistance any worse than it already is. There is obviously room for debate on this issue, and I am certainly not an expert by any stretch of the imagination.

Failing to offer PrEP to appropriate patients is just as bad as failing to offer vaccination to a child. It is an opportunity to prevent disease that is being overlooked because it is “uncomfortable” to ask patients about sex. It should not be surprising that physicians are failing to offer PrEP, because we also have an abysmal track record of offering HIV testing. The CDC recommends that patients between the ages of 13 years, and 64 years be screened for HIV. The American College of Physicians recommends that physicians make HIV testing a part of routine health screenings. When was the last time your doctor suggested that you be tested?

Last time I checked, we do all kinds of things in medicine that make patients uncomfortable. We need to ask our patients about sex. Are they having sex? With what types of people do they prefer to have sex? Do they have one partner, or several? Just because a patient is elderly doesn’t mean that they aren’t having sex. Just because someone is in a relationship with a male at the present time doesn’t mean that they aren’t now, or have never had sex with a female. Just because a patient is married, doesn’t mean that they are monogamous. In order to know who to offer PrEP to, we need more information about our patients’ sexual practices.

To get this information, patients need to feel safe talking to us. There have been times when I have been a patient myself, and a physician would say something along the lines of “So, do you have a girlfriend?” This does not make me angry. Both as a medical student, and as a gay man this just makes me mentally sigh. I sit there and contemplate if it’s worth it or not to correct the situation. To educate the physician that no, I do not have a girlfriend, but I do have a boyfriend. Should I suggest that the physician should try more open ended questioning, signaling that he/she is ready to hear my story if I am ready to tell it.

The medical profession has a long track record of failing to promote preventative healthcare. It also has a track record of avoiding issues that are “uncomfortable”. It really should be no surprise that we have failed so profoundly to offer HIV screening and PrEP to our patients.



My Apologies

Dear readers, it was my plan when I started this blog to post on Tuesdays and Saturdays. This coming Tuesday however, I am taking USMLE Step 1, and you will have to wait to hear from me until after my exam. Until this Tuesday I will be studying myself into a frenzy, wish me luck.


Big Pharma is not our enemy… but not exactly our friend either

Disclaimer: I took one semester in economics in college, I am by no stretch of the imagination an authority on such a topic. I welcome criticism in the comments.

I have always defended pharmaceutical companies with regard to the patent protection they enjoy. As someone who has done research in molecular biology, I have had a glimpse at how expensive it is to carry out the type of work that leads to the discovery of a drug. My research project was really a drop in the bucket of research knowledge; small potatoes so to speak. I once paid over $700 for 10 micro liters of reagent… that particular reagent ended up not working out by the way.

If you “scale up” the size of a research operation to the size of a pharmaceutical company, imagine how much money and time goes into coming up with a drug candidate. Now imagine that it didn’t work out the way you had hoped… bummer. I only wasted $700 on my puny research project. A pharmaceutical company may find out several years in that they’ve wasted several million dollars. If they intend to keep the lights on, they need to make that money back. They also need to make the money back that they put into developing drugs that actually go to market.

Like any other business, pharmaceutical companies give us what we want. For example, we wanted a cure for hepatitis C, and we got one. Big pharma brought the power of modern molecular biology to bear on the hepatitis C virus, found its weakness and dealt it a fatal blow. And when a warrior comes home from battle he expects a feast. Rightfully so.

Now before anyone accuses me of working for big pharma (I don’t, I promise), here comes the criticism. It is a fact that Sovaldi (sofosbuvir) is a game changer. It is revolutionary. It is a great victory over a terrible disease. I believe, that it may also be at least a little bit overpriced (insert sarcasm)… but my freshman level economics course tells me that this drug’s manufacturer can command almost any price they choose. It is the only product of its kind, it is incredibly valuable, and therefore people will pay.

I can’t help but feel a terrible sense of injustice here however. They taught me in medical school that hepatitis C can kill people, and the cure is prohibitively expensive for many people who need it. This creates a situation where the haves are cured, and the have-nots are left to accumulate toxins until their bodies’ own metabolic wastes drive them into a coma, and then into the grave. This time, I think big pharma has overstepped their bounds with regard to pricing.

I admit that I am torn on this issue. If we want pharmaceutical companies to put in the money and time to give us revolutionary, breakthrough drugs, we should be prepared to pay the piper. That is only fair. However in this particular situation, my sense of social justice is particularly offended. I have a feeling it won’t be the last time.


We are taught patient profiling

I recently read an article entitled, “Are you a victim of patient profiling?” on KevinMD.com (link to article) and it got me thinking about my medical school career thus far, particularly my recent preparations for USMLE step 1.

Patient profiling is part of medical school curriculum. Many of the practice questions that I’ve done for step 1 have relied on patient profiling (a euphemism for prejudice I believe) to get the correct answer. If the question starts out with “The patient is a 35 year old African-American female…” a list of diseases already begins to populate in my mind: sickle cell anemia, sarcoidosis, and fibroids all come to mind in the first 0.5 seconds, and I don’t even know her symptoms yet.

If you were to change the question to “The patient is a 35 year old Asian-American female…” my mental list of prejudiced diagnoses changes drastically: Takayasu’s arteritis, or perhaps alpha-thalassemia.

How can one possibly expect that these types of snap judgments that we are taught to make during the first 2 years of medical school, and are thoroughly reinforced during weeks on end of studying for a board exam, will suddenly go away? How can we be expected to keep an open mind, and consider all of the diagnostic possibilities if we are trained to jump to conclusions based on such a meager amount of information?

Please don’t misunderstand me; it is true that certain groups of individuals are disproportionately affected by certain illnesses. Having knowledge of these differences is a good thing, because it can help to bring relevant diseases to one’s mind. However when that knowledge gets in the way of listening to the patient, and understanding that individual patient’s story we can run into trouble. Indeed, we could really harm our patients (I seem to recall reciting some oath to the effect that we’re not supposed to do that) if our judgment is too clouded to hear them out. Medicine is not one-size-fits-all.

Of course, it is easy for me, as someone who has yet to enter the clinical phase of my training, to get up on my high horse about such things. I’ve not yet been “in the trenches” of clinical medicine. I am far from perfect; there are plenty of people who would tell you so. I too will inadvertently wield medical prejudice as a tool to attempt to make quick work of my patients.

I believe that prejudice is a part of the human condition, no matter how much we may like to believe that it is not. We all make snap judgments. What we can do is struggle against it, but the first step is to acknowledge that we pre-judge. From there, we can try to keep vigilant, and remind ourselves to keep an open mind when we feel that snap judgment coming. We must make a concerted effort to grow in this area, not only as a medical community, but also as human beings.