One Step at a Time... What Durham is Doing to Increase PrEP Access


One Step at a Time... What Durham is Doing to Increase PrEP Access

by Dr. Barbara Johnston

Don’t it always seem to go that you don’t know what you’ve got till it’s gone. Pave paradise put up a parking lot. Joni Mitchell Big Yellow Taxi

I really am that old, to remember when that song came out. Old enough to have been an Intern in the Bronx when the AIDS crisis hit. Hard. Thankfully it is (mostly) ancient history now, the years of dying, alongside, often literally at the bedside of my patients.

What different times we live in! Still no cure, but people are living healthy lives, most have undetectable viral loads, or what is the same, close to it.

They can’t transmit the virus.

The problem is, it’s still not enough. Too many people still don’t know their status, and with rates of STIs (sexually transmitted infections) fueling the transmissions of new infections with high viral loads efficiently transmitting the virus, we need more tools. Condoms, yes they work, but still, 30 years into the epidemic, are clearly not the answer.

PrEP, or Pre-exposure Prophylaxis, is a daily pill proven to cut new infections by more than 90% for those who take the medicine. PrEP came on the scene in 2012. In some parts of the country, notably New York City and San Francisco, PrEP is contributing mightily to a sharp decrease in new infections. San Francisco just reported a dramatic 60% drop in the last decade in new HIV cases, 221 in 2017. As comparison, in Durham our new cases were 65 in 2017, down from 82 the year before, with our average case rates stable around 26.8/100,000 since 2013.

In the South, particularly among our hardest hit populations, the promise has been slow in coming for Black and Latinx Men who have sex with men and our vibrant Transgender community. The CDC estimates that 44% of people who could most benefit from PrEP are African Americans, but only 1 percent have been prescribed it. Latinx individuals were 25% of the population who need PrEP, with only 3% prescribed; 75% of the prescriptions have gone to white men who have sex with men, mostly in the Northeast or West.

Maybe you’re wondering what the lines at the top have to do with this.

I happened to be listening to the song when I had the realization that we in the South have the exact opposite problem.

We have never had the health care, or health care system that others have, so we don’t know what we haven’t got enough to miss it. California and New York have some of the best health systems in the country, having taken advantage of the expanded health care, including Medicaid, through the Affordable Care Act (though there are admittedly still holes enough there to drive a truck through, but that’s for another day).

In other developed countries, as well as in some less developed ones, people who need PrEP are able to hear messaging educating them on the need and availability of the medication, can go into their doctor’s office or clinic, easily get the necessary tests, and pick up the medication at their pharmacy.

As the Chief of HIV Services/Early Intervention Clinic, we knew we had to figure out how to treat a mostly uninsured population, when the lab costs alone were going to run into the hundreds of dollars (HIV, Hepatitis B and C, GC/Chlamydia testing at all exposed sites, blood chemistries). We were lucky. One of our new clinics at Lincoln, the Primary Care Clinic, occupied free space through the Durham County Department of Health. The County Medical Director, Dr. Arlene Seña, had convened a task force to get PrEP moving in Durham County. Right place, right time. The Health Department would provide the initial testing, and we would provide both PrEP and primary care to a people who needed it--predominantly young Black and Latinx men (75% of our PrEP population). With one expert in Transgender care, we could provide full care to that population too.

Easy, right? Not so fast. We took the plunge to provide PrEP, but there were (and still are) twists, turns, barriers, if not outright roadblocks. The first is that Lincoln is not free—and to be fair it can’t be, the government does not come close to fully funding everything, provider and staff salaries and all the other parts of a major health care organization. Young people are notorious for not coming in for routine health care--especially when they don’t feel sick. We had to convince the Board to lower fees for the lowest income group from $20 to $5 to bring them in. We had to try to make sure spaces on the clinic schedule were available, which is no easy feat when the wait for routine health care can be over 3 months. Convincing people of the need to take time off from work or school for the mandatory quarterly HIV and STI checks was, and is another matter. Last, but certainly not least we had to shift our staff from their accustomed nursing tasks to specializing in applying for patient assistance programs and insurance co-pay cards. Eventually Lincoln stepped up and provided a case manager to assist with these tasks and provide on-going case management for our patients

The point? With incredibly dedicated staff and a receptive administration, with a huge dose of leadership and assistance from a determined Health Department, a system can be cobbled together that works, albeit with hitches, to provide PrEP that can reach the populations that need it. It could be easier though, if the country made it a priority, or at least if the South had access to the same health care through expanded Medicaid that other states have. One step at a time…

To access PrEP if you live in the Triangle region of North Carolina:

  • Get initial testing through Adult Health Clinic (Clinic 6) at the Durham County Health Department, where they complete a thorough lab evaluation, and help patients who need PrEP get appointments at Lincoln.

  • Can walk-in or call 919.560.8819

  • Visit to complete an application for free/low-cost PrEP!