The Baltimore Health Department will announce Thursday it has received more than $20 million in federal funding for a new HIV strategy that will target gay men and transgender people and push a drug that can prevent people from contracting the disease.
Under the initiative to be developed with two grants from the Centers for Disease Control, city officials will partner directly with 11 community and provider groups in the largest collaboration in recent history to combat HIV, health officials said.
The strategy will focus less on trying to get people to change their sexual behavior and more on testing, treatment and helping people with social problems, such as poverty and drug abuse, that may play into whether they get care.
The grant follows an executive order President Barack Obama issued in July calling for such broader strategies to reach populations that have stumped efforts by public officials to eradicate HIV amid advancements such as rapid testing and anti-viral drugs that make the virus nearly undetectable in many people.
Baltimore is among several cities getting funding from the CDC.
"This is a very organized approach to HIV that we are trying to get people to know their statuses, get them into care and keep them in care," said Patrick Chaulk, assistant commissioner for HIV and sexually transmitted diseases at the city health department and lead investigator on the grant application. "We are going to start with the highest risk, most marginalized folks and then take lessons from that to broaden the effort."
New HIV infections have declined across the country, including in Baltimore, but are increasing in gay men and transgender people.
About 13,400 people in Baltimore are diagnosed with HIV and more than 40 percent of new infections in the past couple of years were gay men. Transgender numbers are hard to track because some may identify as women.
Health officials believe another factor contributing to the persistent spread of the virus is the 1 in 5 people who don't know they are carrying it.
A significant part of the new strategy involves better marketing of PREP, a drug given to people who engage in risky behavior that can reduce their chances of contracting the virus by up to 92 percent. Approved by the Food and Drug Administration in 2012, the drug is not used as much as health officials believe it could be.
PREP, short for pre-exposure prophylaxis, is a pill taken every day. It's a mix of two medicines used to treat HIV that can keep the virus from permanently infecting someone when they are exposed.
The effort will include counseling and support to help patients adhere to the drug.
"It is just not a medication, it is a program," Chaulk said. "You have to work with patients on behavioral changes, testing themselves, keeping doctors visits. You have to make sure they stick to the program."
Chaulk and others believe people are not using the drug in large numbers because they don't know about it.
Chase Brexton Health Services in Baltimore has prescribed PREP to 129 patients, but officials said there is some stigma attached to its use.
"A lot of folks are in the closet about PREP," said Ken Ruby III, Chase Brexton's director of operations for HIV care continuum and social work. "If you are taking it, people may think it's a promiscuous, slut kind of thing. There is a lot of destigmatization that has to happen and discussions about making sex more positive."
Chase Brexton has tried different approaches to teach people about the drug, including telling patients about it during HIV testing appointments. Officials there think the new initiative will provide more resources for their efforts.
Stigma is just one of the reasons health care providers say gay men and transgender people may have fallen behind in attempts to curb HIV rates.
In Baltimore's most impoverished neighborhoods many are more worried about meeting basic needs, such as where they will get their next meal and whether they could become a victim of violence. Young gay men, ostracized by their families, may turn to the sex trade to support themselves or move in with older men whom they feel obligated to please.
The latest approach also will include connecting people to health insurance as well as other "wrap around" services that address issues with housing, mental health, substance abuse and others life stressors.
"This group of young men has faced many obstacles throughout the course of their lives because they are not open about their sexuality," said Jamie Mignano, director of development and information dissemination for JACQUES Initiative, a program of the Institute of Human Virology at the University of Maryland School of Medicine and one of the 11 partners. "Many are homeless. Many face substance abuse to cope with esteem issues. It goes a lot deeper than HIV. We will not be successful if we are not able to address all of their issues.
The funding will allow for the creation of 70 new jobs at the health deparment or at its partners, many of them coming from the gay and transgendered community. Health advocates have found that gay men and transgender people respond best to people who are like them and have faced some of the same obstacle. Many avoid doctor's offices because they worry about being judged and don't feel comfortable getting care.
"We know the most credible messenger for this today is not necessarily medical professionals, but people who are from the community," said Dr. Leana Wen, Baltimore's health commissioner.
The Morning Sun
Chaulk said the health department also wants to take care not to make gay and transgendered people feel further stigmatized in their approach.
"This is really just a wedge into this population to figure out how we best serve them," Chaulk said. "It is as much about racial and social justice as well as HIV."
The initiative will build on many other efforts already taking place in Baltimore. Workers with the health department go into the community to test people at soup kitchens and festivals, and at clubs when they close on Friday and Saturday nights. The department also hosts events where groups compete in dance and performances for cash and trophies — and also can get an HIV test.
The city's latest initiative has the potential for widespread change, said Dr. Robert Redfield, associate director and professor of medicine at the Institute of Human Virology.
"If you do (PREP) and treat the infected population, transmission is stopped and we could end the AIDS epidemic," he said.