Petrelis Files

NY HIV Expert Dr. Bellman on MoJo & PEP

Dr. Paul Bellman is a leading and veteran HIV specialist in New York City with a history of innovative ideas for preventing new infections and treating people with HIV. He sent along his thoughts on the Mother Jones article I blogged about yesterday, with reactions to the haphazard approach to publicizing and administering PEP. From Dr. Bellman:

Hi Michael, if you'd like you can post this as a comment on your blog. I look forward to reading the MOTHER JONES article on Post Exposure Prophylaxis (PEP) that you highlighted on your blog.

I agree that that an aggressive, comprehensive public health campaign that included educating the public and medical profession about PEP would likely prevent new HIV infections. I found Dr. Anthony Uribe's comment that "it needs to be treated like a gunshot wound or stabbing" provocative and worthy of comment. No doubt Dr. Urbina is highlighting the need for both easy and immediate access to PEP and in particular universal recognition among health care professionals and the public for immediate treatment to be sought and granted.

Currently, access to PEP is haphazard and even when it is sought it often times is delayed well past the point when it is most likely to work. There are many obstacles to PEP including often long ER waits for patients who either don't have a physician or whose physician is uncomfortable with prescribing PEP. Delays in seeking or accessing treatment are often caused by weekend or evening exposures. Even patients who have doctors may not be able to make timely appointments based on their doctors schedule or lack of recognition by the doctor's staff of the urgency of the matter.

Patients themselves, already frightened and stressed may not feel comfortable in seeking help, making timely appointments and may worry that they will be judged negatively in some way for needing PEP after a sexual encounter. Patients also may not know whether a particular encounter has put them at risk for HIV exposure.

Patients may also may be worried or in fact be unable to pay for PEP evaluation and if indicated medical treatment. I am concerned, however that equating a sexual encounter that could lead to possible HIV exposure requiring medical evaluation and possibly treatment with PEP with a stabbing or gunshot wound may inadvertently but powerfully equate that sexual encounter with an act of violence.

The equating of an act of love with an act of violence could be highly stigmatizing particularly to men who have sex with men or minority women who are sexually active, two already stigmatized groups in our society that have high incidences of new HIV infections.

It also incorrectly suggests that HIV exposure is a potentially fatal occurrence like a gunshot wound or stabbing. A gunshot wound or stabbing is often immediately fatal even despite the best of medical care. Thankfully, HIV is highly and effectively treatable when medically indicated and acute HIV infection is never a fatal occurrence.

Promoting avoidance of HIV infection is best done by educating the public about the actuality of what HIV infection means in terms of its health impact in 2008. Terrifying, the public which is already unrealistically terrified of HIV positive persons will cause not prevent new infections

There are so many current misconceptions about HIV and HIV positive persons that are highly prejudicial and serve to stigmatize HIV positive persons, gay men , and women living with HIV. Too many to chronicle here but one example is particularly instructive.

A recent survey showed that only 14% of Americans believe that HIV positive women should have children a lower percentage than Americans believe women with Down's syndrome or schizophrenia should have children. In fact, HIV positive women are fully capable with appropriate medical treatment of having healthy babies, meeting the challenges of motherhood, and living to enjoy having grandchildren.

The shocking ignorance of the general public about HIV positive women is just one of many signs of a failed public health campaign to prevent HIV infection and to effectually treat HIV positive persons in a compassionate and intelligent way.

The "don't ask, don't tell" ethos that was described by the enlightened North Carolina public health official Peter Leone who would like to ,better access to PEP in this area is on target.

On the other hand, Dr. Robert Janssen, the powerful head of the CDC Division of HIV/AIDS states that "Biomedical interventions raise concerns that people would feel "Oh I have these pills. they will keep me from getting it." If those "biomedical interventions" worked and were found to be safe and effective what's the problem with that.

I believe that the best chance we have to prevent new HIV infections as well as effectively treating HIV positive persons depends upon comprehensive public health education about HIV that in which the medical community partners with not preaches at the public.

In my opinion, it's time for new leadership particularly at senior levels of public health agencies at the NIH and CDC who consistently have placed the discriminatory and unenlightened ideas of the Bush administration above meeting the challenges of HIV prevention. A new public health campaign is urgently needed that de-stigmatizes HIV positive persons once and for all and a public health leadership that focuses clinical and research resources in meeting the current prevention and treatment challenges of HIV today.