HIVE presented during the public comment portion of the recent NHAS PrEP listening session.   Comments and slides are below.  #WheresMyPrEP

HIVE comments for NHAS PrEP Listening Session, June 20, 2016

Dr. Dominika Seidman & Shannon Weber

Thank you to the office of HIV/AIDS & Infectious disease Policy and federal organizers for hosting this PrEP listening session and allowing public comment.

Since 1989, HIVE, a hub of positive reproductive & sexual health based at Zuckerberg San Francisco General Hospital, has provided prenatal and preconception care to women living with or affected by HIV. We began offering PrEP to women in and around pregnancy in 2010.

In collaboration with colleagues at Bronx Lebanon hospital in New York, we recently completed a retrospective chart review of women offered PrEP preconception, during pregnancy or postpartum. This data will be presented in full next month in Durban. We found: 50% of women offered PrEP also experienced unstable housing, 20% had ongoing intimate partner violence, and 20% were actively substance involved.

Similar individual, community and structural factors that affect women’s vulnerability to HIV also affect women living with HIV, impacting our ability to attend appointments, to take meds, to adhere to meds, to get our labs drawn.

In addition, many of the most vulnerable women ONLY access health care when pregnant: in fact, over half of our patients using PrEP were identified during pregnancy, after safer conception opportunities for the current pregnancy were missed. In and around pregnancy, as providers we piece together services available to women through maternal health services and HIV services – a patchwork approach. However, when pregnancy ends, especially for women vulnerable to HIV, support wanes. This is even more striking at clinics in states where the Affordable Care Act has not been implemented or Medicaid non-expanded states.

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“Getting diagnosed with HIV was the best thing that ever happened to me.”

-female client, Ward 86, Zuckerberg San Francisco General

In San Francisco, as well as many other jurisdictions, an HIV diagnosis facilitates access to case management, housing, medications, mental health and support systems that are out of reach of individuals at-risk of HIV. We have much to learn from the incredible work done by and for women living with HIV.

We see women in and around pregnancy when they are engaged with healthcare, and this is some of the only data we have about US women’s PrEP use. But after delivery, we lose touch and loose the ability to support these women in the same way.

Women vulnerable to HIV have access to limited services that would mitigate these intersecting barriers. Just like women living with HIV, the need housing, intensive case management, substance use treatment, mental health services, parenting support. Without these services, highly effective prevention services will not work, similar to how we have learned the importance of support services in HIV care and treatment.

As an example, our institution cared for a woman during pregnancy whose partner was living with HIV. During pregnancy, she was in care, and had frequent testing. She was lost to follow-up after delivery, and represented 10 months post-partum and was diagnosed with HIV.

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How can we support women both during times of intensive healthcare engagement, and afterwards when they tend to fall out of healthcare? How can we support women at risk of HIV in ways similar to those in which we support women living with HIV? 468,000 US women want to know.

A siloed approach to care and services will not work. The current integration that is happening in HIV treatment, including integration of services, health care provision, all provided with a trauma informed lens, needs to occur to serve women vulnerable to HIV.

Moving from a chronic disease model to an integrated treatment and prevention effort incorporating support services Is required. PrEP is more than a pill. It’s an opportunity to offer women access to comprehensive and integrated health care meeting our sexual and reproductive goals throughout our lifetime.