Diana Howard, MD, an HIV specialist and UCSF assistant clinical professor of Family and Community Medicine at UCSF Fresno, is blunt when she talks about the risk of contracting the virus that causes AIDS if you live in Fresno or other counties in the San Joaquin Valley.
“If you are sexually active, you are HIV-possible in Fresno. That’s how I see it.”
Howard cites the latest California HIV Surveillance Report that shows Valley counties as being among the top five in the state for the rate of people with newly diagnosed HIV infection per 100,000 population. Kern County has the highest rate at 22.9, followed by San Francisco at 20.7; Merced, third, at 18.2; Fresno, fourth, at 17.2; and Los Angeles at 16.0.
Prevention is the key to stopping the spread of HIV, and there are options, from daily pills to new long-acting injectable medications that prevent someone who is HIV-negative from getting infected. Unfortunately, few people are aware of their choices, particularly that injectable PrEP (pre-exposure prophylaxis) drugs are available, Howard says. “We know about injections to lose weight, but people don’t know that we have injections that can prevent HIV.”
Howard is co-chair of the California and Hawaii chapter of the American Academy of HIV Medicine. An Inspire Health Medical Group family medicine physician, she sees patients at Community Health System’s Special Services Clinic and at the UCSF Fresno Family Medicine primary care clinic at United Health Centers-Ambulatory Care Clinic (UHC-ACC). She is helping educate people in the Valley about prevention and, for those with HIV, how to successfully manage the virus.
She considers the new injectable PrEP medications to be a gamechanger for many. While a daily pill to prevent HIV infection, Truvada (emtricitabine and tenofovir disoproxil fumarate), has been available since 2012, it can be easy to forget to take a pill once a day, she says. “You have 365 chances to miss your dose.”
The injectable PrEP medications, the two-month Apretude (cabotegravir) and the six-month Yeztugo (lenacapavir), are ideal for someone who may not be able to take medication every day, or who has issues, such as substance use, which can prevent them from having compliance, Howard says. And for patients who are unhoused, medications can be stolen, but “If you get your shot, you don’t have to worry about that.”
PrEP medications are accessible to most patients, Howard says. Medi-Cal, the government insurance for people with low incomes, covers injectable medications with no copayments. Private insurance companies require pre-authorization but will cover the medications once approval is granted, Howard says. The two-month injectable is available at the Community Special Services clinic and at the UCSF Fresno Family Medicine clinic at UHC-ACC. The six-month injectable is available only at the UCSF Fresno Family Medicine clinic at UHC-ACC.
The injectable medications require a negative HIV blood test before getting a shot. For PrEP pills, a blood test is required every three months for prescription refills.
PrEP medications, injectables, and pills are not a form of contraception. They do not prevent pregnancy; however, they are safe to take during pregnancy, Howard says. PrEP medications also do not protect against other sexually transmitted illnesses.
Long-acting injectable PrEP can interact with certain medications, including some treatments for tuberculosis and some anti-seizure medications. These medications can reduce the effectiveness of injectable PrEP. Depending on the specific PrEP medication and the interacting drug, the patient may need an alternative medication, supplemental PrEP dosing, or discontinuation of the injectable. Patients should discuss all medications with their physician before starting injectable PrEP so the safest and most effective option can be selected.
Informing patients about HIV prevention and the choices they have is the main goal, Howard says. “My concern is when patients don’t know that PrEP exists. The discussion should be a part of a regular preventive health exam, she says. “Let me tell you about PrEP as a pill or a shot that can give you total autonomy over your sexual health against HIV.”
