HIV infections among teenagers and young adults in Fresno County are at their highest levels in years and there's concern of an outbreak or epidemic if the trend continues.
The young people diagnosed with HIV are from all regions of the county and include college students.
"Start paying attention, folks, this could be your child," says Toni Harrison, who runs The Living Room, a nonprofit in the Tower District that provides social services to people with HIV.
In 2017, Fresno County reported 15 preliminary HIV infections in youths between ages 15 and 19. And there were 31 preliminary infections among young adults between ages 20 and 24. The numbers, which have not been finalized, are the highest in the county since 2010.
Between 2010 and 2016 the county reported only a handful of infections among adolescents yearly, and to have 15 cases in 2017 is a dramatic jump that health officials are studying. The sharp increase in teen numbers could be a one-year blip, but county health officials have been closely following the numbers of young adults newly diagnosed with HIV.
In 2010 there were nine infections among youths between the ages of 20 and 24, and the number of infections has not been that low since. In 2014, there were 19 infections, 21 cases in 2015 and 25 infections in 2016.
The HIV infections among teens and young adults are 29.1 percent of the 158 total HIV cases in Fresno County in 2017.
"We're actually passing San Francisco now for the number of new infections, which to me is stunning," says Dr. Simon Paul, medical director of the Specialty Health Center at Community Regional Medical Center where people with HIV infections go for care.
San Francisco, which has been the epicenter of HIV in California since the 1980s, reported four cases among youths between ages 13 and 19 in 2016 and 27 infections among young adults. They were out of a total of 223 HIV infections in 2016, the latest numbers available.
Paul is an HIV doctor and not an an epidemiologist who studies health trends, but he uses "outbreak" when describing the latest HIV numbers in Fresno County. In April, he sent an email to officials at the Fresno County Department of Public Health about concerns, including an observation that new infections have increased since the county closed a clinic for HIV treatment and sexually transmitted diseases in 2010.
"I guess what tipped it off was when I had a whole bunch of young kids, college kids, coming in with new infections," Paul says. "You get four or five kids in a row and you go, 'Whoa, what's going on? Right? And why is nothing being done?"
A need for prevention, care
It's unsettling that HIV infections are increasing at a time when antiviral medications to reduce transmission and a pill that can be taken daily to lower chances of getting infected are available. Easy access to prevention and treatment services are considered crucial to reducing infections. The concern is that too few young adults in Fresno County are getting tested and beginning treatment if they test positive. And many youths at risk of infection also don't get the pre-exposure prophylaxis medication called PrEP, either because they don't know about it or they don't have a doctor who will prescribe it.
"The problem is there's a lot of HIV out there and there aren't a lot of people on treatment, so that's why they're catching HIV," Paul says.
Fresno County officials say they share the concerns and are focused on reducing new HIV infections among youths, but it's unfair to compare case numbers in the county to San Francisco. "That's like comparing kiwi to watermelon," says Jena Adams, supervising communicable disease specialist at the Fresno County Department of Public Health. "San Francisco has an infrastructure that Fresno County will never have," she says. "It's just a completely different atmosphere."
San Francisco's HIV program has had financial support from the city and outside sources, as well as from the state, to build a big budget — about $57 million this fiscal year — to fight new infections. Since 2010 it has developed a complex system of outreach, testing, prevention and treatment.
The Fresno County health department gets funding for HIV prevention only from the state. This fiscal year it received $296,685. And the county has not restored HIV services to pre-2010 levels when a sexually transmitted disease clinic offered HIV testing, counseling and treatment. The STD clinic now offers HIV testing but refers HIV-positive patients to doctors outside for care. The clinic has limited testing and treatment for syphilis.
Health officials made the decision to essentially close the STD clinic in 2010 to save about $523,000 and help plug a $5 million hole in a $54.8 million department budget to keep everything from restaurant inspections to flu-shot clinics open.
State health officials say there's no direct evidence to prove that county HIV clinics help reduce infection rates, but they do provide important services that are key to prevention. Twenty counties in California have HIV clinics. In the central San Joaquin Valley, Madera and Tulare counties offer testing and the pre-exposure prophylaxis PrEP. Kings County offers testing. Merced County closed its STD clinic in 2013. Merced offers HIV testing only at mental health rehabilitation sites in the county.
Plans for providing care
Fresno County is developing a prevention plan for 2019, but it likely will not include reopening the HIV clinic to provide treatment and to prescribe PrEP.
"We are looking at how to increase prevention and treatment offered by primary care providers," says David Pomaville, director of the county's health department. "We believe this is the most complete and sustainable solution."
More money for STD prevention in California could be available for the next fiscal year. State legislators approved $2 million for STD prevention services and the bill is on Gov. Jerry Brown's desk for signature. "The $2 million investment in STD prevention will support outreach, screening and other core services and will target areas with high incidence of STDS, like Fresno," says Assemblyman Joaquin Arambula, D-Fresno.
Adams says a health department goal is to increase testing for HIV by screening for the virus in individuals who test positive for syphilis or gonorrhea, two of the most prevalent STDs in the county. Doctors in the community also will be encouraged to routinely offer HIV testing to patients as part of standard laboratory screenings.
And Fresno will be the location for a PrEP summit this summer that brings people from health departments throughout the state together to talk about increasing PrEP utilization, Adams says.
Health officials and doctors agree on the value of the single-pill PrEP (brand name Truvada). It became available in the United States for adults in 2012 to prevent individuals who don't have HIV from being infected through sexual activity or injection drug use. In May, the U.S. Food and Drug Administration approved it for ages 15 and older. PrEP is estimated to decrease the risk of infection by probably 90 percent, but it is recommended in combination with condoms to prevent infection.
A Kaiser Permanente study published in 2015 found no new HIV infections among patients on PrEP over a 2 1/2-year period.
Dr. Dee Lacy, an infectious disease specialist at Kaiser Fresno, says more people are requesting PrEP, but not many of the patients are adolescents and young adults. "That is a population that is perhaps less informed than the older patients," she says. And she's frustrated when someone with a new HIV exposure was unaware that PrEP could be prescribed.
San Francisco bus stops have the message: "Ask your provider about PrEP — it stops with me. I'm not going to get HIV," Lacy says. "We don't have that kind of thing in our community."
PrEP is an incredible tool to prevent infections, Harrison says. "People should be aware of that, especially folks with multiple sex partners." But budget cuts have affected funding for HIV education and awareness, she says. The Living Room, which has provided HIV services for 22 years, has scaled back on what it provides.
An 18-year-old Fresnan says it's important that adolescents have access to PrEP. He tested positive for HIV a year ago and talks anonymously because only some members of his family know his diagnosis. Three years ago, there was no information at school about gay sex or the pre-exposure prophylaxis drug and he turned to YouTube to learn about PrEP. He tried to get a prescription — but at that time he was too young.
"We do need resources for students, for younger students, in high school," he says.
Youths today are getting some education about HIV and PrEP under state-mandated comprehensive sex education programs that require lessons that are LGBT inclusive. Fresno Unified provides information about HIV prevention as a part of Positive Prevention Plus classes. HIV testing is offered at the health center at Gaston Middle School. Fresno Economic Opportunities Commission offers information about HIV, including PrEP, to youths in its California Personal Responsibility Education Program.
But the 18-year-old says he questions whether schools are providing information in an effective, youth-friendly way. "Adults who have the power are not listening to youths," he says. "And their strategies are not working now."
Social media is a fast way to spread the word about HIV testing, treatment and prevention, Harrison says. "One message on an app that is used widely by young adults can hit 10,000 people in two seconds." Adams says Fresno County purchased ads in 2016 for a syphilis campaign on Grindr, a gay dating app, and the county is working with an advertising agency this year to develop advertising for HIV and STDs.
Harrison says any message about PrEP should emphasize that testing is still important. Some youths mistakenly believe there is a cure for HIV, she says. "They see HIV now as no big deal, 'I'll take a pill and I'll be fine.'"
Stigma continues to stifle conversations about HIV, Harrison says. "Ignorance, stupidity, prejudice, all those things still play a role in being HIV-positive. And people are afraid they are going to get beat up, get killed … be exiled from everything they know because somebody says you're HIV-positive."
Savun Sean, 38, says he felt afraid and alone 11 years ago after being diagnosed with HIV. At that time, the Fresno County STD clinic offered treatment and he was assigned a case manager and a doctor prescribed medication. The Living Room provided social support and other services. It all helped, he says. Today his viral load is undetectable.
Sean's message to young adults: "HIV is alive and well. Protect yourself. Remember your life is your responsibility. And use protection. PrEP is not a vaccine and it's not a cure for HIV."
Doctors need education, too
Doctors also need education about PrEP and encouragement to offer it to patients who are at high-risk of HIV. Only about 34 percent of primary-care providers nationwide knew about PrEP in 2015, says Sampath Wijesinghe, an HIV specialist and physician assistant at Adventist Health Medical Office-Sanger. Wijesinghe began offering PrEP in 2016 and has prescribed more of it than just about any provider in the central San Joaquin Valley.
But a vast majority of people in Fresno County who want PrEP have a limited number of places to easily get it. Besides Wijesinghe and Kaiser, the other large providers in the county are Planned Parenthood Mar Monte and the United Health Centers of the San Joaquin Valley clinic in Parlier.
Any doctor can prescribe PrEP, but takes time to counsel patients, and primary-care doctors are pushed for time. Some of the doctors have full patient loads and can't add new patients, says Maria Baldovinos, a communicable disease specialist at the Fresno County health department who has been trying to add PrEP providers.
And some doctors may have another reason for not becoming PrEP providers: They are not comfortable having a conversation about sexuality with patients. "Many of them don't even know that their patients are gay," Baldovinos says. Males who have sex with males are the majority of the young people identified as having new HIV infections.
Doctors in coming years could be more comfortable discussing risk factors for HIV and offering PrEP to patients. Dr. Robert Shankerman, chief medical officer at United Health Center's Parlier clinic, is training medical residents in the UCSF Fresno Family Practice Residency Program. Wijesinghe is an assistant clinical professor at UC Davis and Samuel Merritt University in Oakland. Paul, a UCSF Fresno professor of clinical medicine, has residents who rotate at the Specialty Health Center.
And some doctors are stepping up on their own to become PrEP providers.
Dr. Dan Little, a staff physician at the Fresno State health center, rolled out a PrEP program at the university last fall. Little saw it as a necessity. It had been difficult finding places for students to be seen and prescribed PrEP.
And he had evidence that HIV prevention was needed. "We have seen students here who have been diagnosed with HIV infection, not in large numbers, but even one is more than we would like to see."
Little says he is sure there are more students who may be at risk of HIV infection and who do not know about PrEP. Fresno State has posted information on the health center web site, and center staff try to get the prevention message out to students, he says.
HIV can happen to anyone, Harrison says, with a message to parents: "I don't care if you live on the north side, Fig Garden, down here in the Tower or down on the south side.. It could be your child."
The Living Room has been providing HIV services for 22 years, and these days Harrison is seeing too many young adults in need of help. "If we don't pay attention, if we don't act soon, I personally am very afraid we are going to have an epidemic."
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