MATT MCCLESKEYYou're listening to The Kojo Nnamdi Show on WAMU 88.5. Good afternoon, I'm Matt McCleskey sitting in today for Kojo. Later in the broadcast, he left D.C. for what he had called the worst place to live in America and hasn't looked back since. We'll hear from author Christopher Ingraham. But first a few weeks ago the D.C. Department of Health released its annual data on sexually transmitted diseases in the District. Among the findings an acknowledgement that HIV diagnosis will not be cut in half by 2020 as had been the original goal.

MATT MCCLESKEYIt's not all bad news, though. In fact, new HIV diagnosis in the District are on the decline just not as quickly as hoped. Still the District identifies more new cases of the virus than all 50 states. And in some communities the HIV epidemic is far from over. Joining us now to talk about the progress that has been made and areas for improvement are Michael Kharfen. He's Senior Deputy Director of the STD, Hepatitis and TB Administration at the D.C. Department of Health. Thanks for being with us.

MICHAEL KHARFENThank you, Matt.

MCCLESKEYAlso Sarah Henn, Chief Health Officer at Whitman-Walker Health in D.C. Thank you for being here.

SARAH HENNThank you.

MCCLESKEYMichael Kharfen, I'd like to start with you. Let's first address the current state of HIV in D.C. How many people are HIV positive in the District?

KHARFENSo thank you, Matt, for the opportunity to talk about this health condition in the city. So right now we report about 12,300 residents that are currently living in the District that are living with HIV. We've seen progress as you noted over the years in terms of decreases and new HIV diagnosis. Back in 2007, we had over 1300 persons newly diagnosed with HIV. And as of 2018, we have 360 and that's a decrease of 73 percent, which is pretty profound successful. But we still have new diagnosis of HIV.

KHARFENBut we've also seen improvements in terms of persons getting into care. Right now we have about 85 percent of persons, who are newly diagnosed are within care. That we mean by seeing an HIV medical provider like Sarah for instance, within 30 days and that's an accomplishment. When before 10 years ago only half of people were actually even seeing providers within like say six months.

MCCLESKEYAnd we definitely do want to get into some of what has worked over the past decade and past years. And look at some of the areas for improvement, but first, how does D.C. compare with other cities around the country?

KHARFENWell, we have a significant epidemic here in the District. So we have about just under two percent of our population and the World Health Organization considers any proportion of a condition like HIV at greater than one percent as to be a significant or severe epidemic. So we do have a profound epidemic here in the District. And that compares with some cities. We're not number one anymore. We used to have that distinction, but we're still within sort of the top 10 of cities with HIV rates. But we also have -- and this has been an aspect of our epidemic, it's a very diverse one. We have lots of different populations that are -- that have HIV, which has been somewhat different than other cities in the country.

MCCLESKEYWell, what has been the District's plan to try to combat the epidemic here and what have been Mayor Bowser's goals specifically?

KHARFENSo in 2016 Mayor Bowser released her 90/90/90/50 Plan to end the HIV epidemic in the District of Columbia. Our goal was by the year 2020. And those goals were 90 percent of persons with HIV would know their status. Ninety percent of those persons or diagnosis would be on treatment. That means taking HIV medications, and then 90 percent of those persons on medications would achieve viral suppression.

KHARFENAnd what we know that's significant about viral suppression is that persons who have that state of HIV both live a standard life span and have a strong immune system. But also they cannot transmit HIV to another person. And that's what we've now coined -- the movement is called U=U or Undetectable Equals Untransmittable. D.C. was the second city in the country that endorsed that scientific finding, and then 50 percent reduction in new HIV diagnosis. And we're making progress on those goals.

MCCLESKEYWell, Sarah Henn with Whitman-Walker Health, I'd like to turn to you. When someone who has never encountered this before what happens when someone goes into a medical facility and says they may have been exposed to HIV?

HENNSo we get them right into rapid testing. We have walk-in rapid testing every day of the week at both our centers. And we're not alone in that in the city. And people will get tests and they will find out their results right then and there. If they do test positive we want to engage them in care with one of our medical providers that day. So they meet with our nurse. They meet with our public benefits team if they need help with insurance and payment. And then they see a provider and hopefully get started on treatment that same day.

MCCLESKEYAnd treatment -- the conversation has changed so much over the past 30 years, 20 years, even the last 10 years. Treatment for HIV and AIDS has changed a great deal during that time. What does long term treatment currently look like?

HENNYou know, it looks really good. We still don't have a cure and we would love to have a cure. But for most people HIV treatment now can be a single tablet taken once a day. And that is far easier than it used to be where people were waking up every four hours around the clock to take medication. So we've made great strides.

MCCLESKEYAnd there are preventative measures as well that you can take if you're in a community that has a prevalence of HIV.

HENNYes. PrEP so Pre-Exposure Prophylaxis. So if you live in a community where there's a high prevalence of HIV, which puts you at increased risk for HIV infection you can take a pill once a day to prevent HIV acquisition. And that's really important and something we're really working in the District to expand. In the last year, I think about 34 -- 3500, is that correct, Michael?

KHARFENYes.

HENNPatients were on PrEP and Whitman-Walker is proud to have treated over 50 percent of those patients.

MCCLESKEYWell, Michael Kharfen, I'd like to turn back to you. As you mentioned the number overall has come down significantly in the past decade. And it is still going down all be it more slowly than the mayor's goals had hoped. Why is that? What was working? Why is it not working now or is it? What do we need to do?

KHARFENSo there is a lot of factors that -- first it's sort of awareness of the different kinds of options that people might have. For instance, having access to PrEP. We want to have -- our plan had a goal of reaching more than 8,000 people and as Sarah mentioned we're at around 3,000 or so that have started on PrEP. We also know that some people, who start actually stop or don't even start. They get the prescription, but they don't fill the medication. And one of the efforts that we're going to undertake with updating Mayor Bowser's plan, which is one of our next strategic steps is understanding more what are those factors and what are those ways that we can improve people both getting access to PrEP and as well as staying on PrEP for as long as they need to be on it.

KHARFENSo one of the other options that we've not very much explored, which is another option for people it's called Post-Exposure Prophylaxis, which is PEP as we call it, which is taking medication after you might have been exposed to HIV. Within 72 hours, you start taking an HIV medications for 28 days and you'll prevent getting HIV. It's kind of a plan B for HIV. And we've not made that widely available and that's one of the strategies that we want to achieve. But another factor in all of this is that how do we address for people to understand their value themselves in that we appreciate and affirm their identities. That we address other factors that are going on in their lives such as housing stability or economic opportunity, and those can be factors where health and HIV kind of drops down the priority list and we want to be able to address the whole person in and effective way.

MCCLESKEYSo it certainly seems like part of the issue is getting the word out making sure people know that these options are out there. And then another is actually getting people to use it. Sarah Henn with Whitman-Walker what are some of the reasons that people don't?

HENNI think there's still a lot of stigma around HIV and I think to what Michael alluded to we need to take a more holistic approach to patients. And we need to confront head on distrust of the medical community, that's existed for a long time in people who are most at risk for HIV. And I think if we do that and we work to change attitudes towards sexuality we can make progress towards engaging people in their own health. And I think that's really important. We need to empower people to want to stay healthy and see taking PrEP and HIV prevention as part of that.

MCCLESKEYWell, Whitman-Walker is not a primary care provider.

HENNNo, we are. We are, absolutely are.

MCCLESKEYYou are. So I'm incorrect there. You absolutely are. Okay, well, I guess the question I'm getting at is do people go to their primary care provider for HIV testing or HIV prevention or do they seek out a more specialized solution?

HENNSo that is actually one of the obstacles. PrEP and HIV care and treatment can actually be part of primary care. Treatment and prevention have become easier to manage and it's something that providers and physicians need to become more comfortable doing. So certainly part of this is increasing education among providers and prescribers in the city as well. People are often seeking out specialists in HIV prevention right now in the city to access PrEP and they shouldn't need to do that. So we need to get more people comfortable having these conversations with patients and engaging them.

MCCLESKEYYeah.

KHARFENAnd change provider attitudes, so one about first talking about sex and sexual health in a healthy way. A lot of providers that we surveyed are not comfortable talking about sex and even though this is a natural part of people's lives. And so then that conversation doesn't come up to understand, well, this might be a good option for you. Or if a patient actually presents and says, you know, I've heard about this. I'm interested in it. And yet some providers are like, well, I don't do that, or I don't know anything about that, when they could be the gateway to helping somebody.

MCCLESKEYAnd what can the city do to help urge providers to make some movement on that end?

KHARFENWell, there's a couple of steps. Some of the work that Sarah and Whitman-Walker has pioneered in terms of talking and reaching out to providers, we've done that, going door to door actually talking to providers about it. Making that a part of their continuing medication education, which is a requirement for their licensure that they understand that PrEP is a preventive health measure.

KHARFENRecently just this year, the U.S. Preventative Services Task Force, which is the national community that looks at all preventive health recommendations gave a grade A recommendation for PrEP. That's the highest rating that it gives, which means that for basically the general population this could be beneficial to individuals. And hopefully that we can get that message out to providers to understand that this could be for anybody that walks in your door. You don't know, you don't need to know exactly, but to know that this might be part of a good health opportunity for them.

MCCLESKEYWell, I'd like to ask you both. First you, Michael Kharfen, who should take PrEP?

KHARFENSo we have some basic sort of recommendations to providers. One is that if the person themselves says, I'm interested in doing this. So they've made some self-assessment about their lifestyle that says that PrEP is right for them. So if somebody comes to you and says, I'm interested in this. The response should be, That's great. Let me tell you about it or let me help you get on it. Otherwise some of the basic factors we look at are if a person acknowledges that they don't use condoms on a regular basis. They may not know the status of their partner or know their partner at all. That PrEP could be very beneficial to them. And that's both for men and women, which is another feature of what has been some of the barriers for PrEP particularly in D.C. where a quarter of our persons living with HIV are women. That PrEP works just as well for women as it works for men.

MCCLESKEYWe have an email from Nancy who says, please ask the guests to clarify that merely living in a community with high HIV prevalence is not a reason to take PrEP, but for people who are at increased risk of HIV. And what those risk factors are? Well, Sarah Henn, throw that to you as well, who should be taking PrEP?

HENNSo I think the community you live in matters actually a great deal. And that's a point I really do want to make, because if you're sexually active in a community with a high prevalence for HIV unless you're always using condoms, unless you absolutely could be 100 percent of your partner's status, I think PrEP is indicated for you. Even if you're monogamous, even you've never had a sexually transmitted infection it's something to consider. The other thing that Michael didn't mention was if you've had another sexually transmitted infection. So anyone who's had chlamydia or gonorrhea or syphilis should think about being on PrEP.

MCCLESKEYWe have one call on the line now. It's David from Woodley Park. David, you're on the air. Go ahead, please.

DAVIDYes. Hi. I just wanted to talk about an experience I had. You know, I went into emergency care at GW Hospital for something unrelated. But when they asked me what my daily medication was and I told them that I had been, you know, that I take PrEP, the nursing staff there was actually surprised and just assumed that I was HIV positive and I wasn't taking it as a preventative measure. And when I explained that to them they didn't seem to be familiar even that was just something that was being taken just for preventative means. So I just wanted to put that out there and ask, you know, is this -- I was surprised to see the medical staff was sort of unfamiliar with it and is this a common thing?

MCCLESKEYWell, thanks for your call, David. Yeah. I'd like to get a response. First Michael Kharfen.

KHARFENUnfortunately that's an experience we've heard before. Some of the -- maybe confusion for some providers is that the medication used in PrEP is also used for treatment of HIV. So it can be used for both purposes. But that's one of the efforts around trying to get more education and awareness around PrEP within our community both for persons to make the decisions for themselves, but then also providers to be supportive of people to do it.

MCCLESKEYSarah Henn, you mentioned stigma earlier around HIV. Why is addressing the HIV stigma necessary to try to eradicate it?

HENNWell, I think that there's an impression that if you're taking PrEP that you're sexually promiscuous or being irresponsible. And actually the absolute opposite is true. You're being as responsible as you can be to protect your health. And so I think, you know, there are people out there, who don't want to take PrEP, because they're concerned to how others will perceive them. If someone finds out I'm on this they'll make a judgement about me and that judgement isn't true. So stigma is a big part of this.

MCCLESKEYLet's go now to Logan calling from the District. Logan, you're on the air. Go ahead, please.

LOGANHi, I just wanted to mention that, you know, I was dating my partner for a month in. I was on PrEP. He was not. And he had previously contracted HIV. At that point in time, you know, we both -- we got tested for everything. And I'm on PrEP so I'm not concerned. But I just hope that other people also realize that there really shouldn't be a stigma around one partner being positive and one not when you are taking PrEP.

HENNAbsolutely. No, I mean, this is a health measure that people can take to empower themselves and be responsible. And we also know that people who are HIV positive shouldn't feel stigma of being in a relationship, because if they are in control of their health, they are engaged in care, they on treatment and they're undetectable, they are not going to infect their partner. So this really is about empowering people to love openly and freely and safely.

MCCLESKEYWe've talk some about the communities with a high prevalence of HIV. Sometimes you hear the word at risk, does that language actually add to the stigma?

KHARFENI believe it does when you attach it to populations. We don't like to talk about an at risk population, but there are behaviors that could be risk for exposure to HIV or other sexually transmitted infections, because people's choices to have an active sex life is not in itself a risk. But it is if there are factors that just as Sarah has described and is described by the callers that if those awareness of your partner's status, that you're safeguarding your own health either by using condoms or on PrEP, those are safe behaviors. So we want to be positively talking in a sex positive framework is not addressing a whole group of people as an at risk group of people.

MCCLESKEYWell, in the couple of minutes we have left, Sarah Henn, first I'd like to ask you, what do you think D.C. is doing well now and what do you think the District could do to improve its approach to HIV prevention?

HENNI think we've made enormous progress in how HIV is treated in the District. In the 12 years, I've been here I've seen HIV infection rates drop dramatically and more people are engaged on treatment. But we do need to work to get people into treatment as soon as they are diagnosed and on therapy. So currently the average time for someone to get on treatment and get undetectable is around four months, so 114 days. And we have medications that get people undetectable in two to three weeks. So there's no reason that someone can't get on medications the same day they're diagnosed and undetectable quickly. And the more we can do that the more infections we can prevent. So that's absolutely one thing.

HENNAnd the other thing is we need to expand uptake in PrEP among people who are at risk. So almost one in every four new infections in the District is among women mostly African American women, yet if you look at our clinic population only two percent of our PrEP users are women. So that's a big disparity. And so we really have to work with women in the community and talk to them and figure out what they need to protect their health.

MCCLESKEYWe got a tweet from Tucker who says, how big a barrier has patient cost been so far to getting PrEP. And he asked, do your guests think this will make a difference? Is cost an issue?

KHARFENCost can be issue for some people. So one of the strategies that we've done is to try to reduce barriers and leverage where both insurance can cover PrEP, which it does or patient assistance programs or D.C. itself. We've setup from the Health Department our own assistance program so that if somebody's insurance is not fully covering the medication or you don't have insurance we'll cover you to start on PrEP. At our Health and Wellness Center, which is at 77 P Street and we changed the name from the STD Clinic to something that much more sex positive and healthy, which is Health and Wellness Center. We'll start people on PrEP for free. We'll give them their medication right there to get them started. And then navigate them through kinds of assistance programs.

KHARFENBut we know that some people still see -- they see that, oh, this costs $1,000 a month. And that -- so before they even get to the stage of asking about it they've already made this calculation that they can't afford it. So we all want to get the message out that this is feasible. And in the next couple of years actually the medication that's used for PrEP is going to become generic. And then there will be far less any cost associated -- or much more lower costs associated with the medication.

MCCLESKEYAnd you would certainly expect it would drop then. Going forward, how is the Department of Health looking to adjust its approach to HIV prevention? Where do you see things headed?

KHARFENSo working with our community partners and doing -- over the next few months we're going to do a very ambitious and vigorous effort around community engagement. We need to hear more from like your callers today and others in our community to say, what are still some of the ways that we can be more effective in getting our messages across? Just last week we had a couple of young men that came to our Health and Wellness Center. One was interested in finding out about PrEP and then we provided them a test just like Sarah was describing. And both of them were HIV positive. And to us that is -- that's somehow our system has failed for them, because we didn't get that information to them early enough to give them that option that even that young and younger -- these were teenagers, that PrEP, it can be an option for them.

KHARFENSo we're going to get input from our communities in ways to get that message across and make sure that there are no barriers for people to get access to both HIV care for a person who is HIV positive and to know that if you get diagnosed at the age of 20, you're going to live more than 50 years. You're going to have a standard lifespan. You can be healthy and productive. And if you want to prevent getting HIV if you don't have it, you can take these options and life that standard life without HIV.

MCCLESKEYAs we said earlier, it's a very different landscape than not too many years ago. Michael Kharfen is the Senior Deputy Director of the STD, Hepatitis and TB Administration at the D.C. Department of Health. Sarah Henn also with me at this hour, the Chief Health Officer at Whitman-Walker Health in D.C. Thank you both so much for joining us.

HENNThank you.

KHARFENThank you, Matt.

MCCLESKEYWe're going to take a quick break. And when we come back we're going to be talking to Christopher Ingraham. He's the author of "If You Lived Here, You'd Be Home By Now: Why We Traded The Commuting Life For A Little House On The Prairie." That's just ahead on The Kojo Nnamdi Show. Stay with us.