PsyDactic welcomes Dr. Jon Lindefjeld for a discussion of the history of HIV and AIDS. In particular, we discuss the development of effective antiretroviral therapies, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), highlighting the CDC guidelines for use and monitoring, need to treat psychiatric com-morbidities, and the importance of monitoring adherence and drug interactions.
Please leave feedback at https://www.psydactic.com.
References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
PsyDactic welcomes Dr. Jon Lindefjeld for a discussion of the history of HIV and AIDS. In particular, we discuss the development of effective antiretroviral therapies, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), highlighting the CDC guidelines for use and monitoring, need to treat psychiatric com-morbidities, and the importance of monitoring adherence and drug interactions.
Please leave feedback at https://www.psydactic.com.
References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
the the opportunity to listen to myself speak is um not one that I'm excited about you don't have to I can just I can just drop it welcome to pactic I am your host Dr oi still a fourthe Psychiatry resident I recording this on the 3rd of February 2024 but it likely won't release for another week or so this is a podcast about Psychiatry and often also about Neuroscience but today I'm lucky to bring you a special guest Dr Yan lindfelt who is a colleague of mine one of his particular interests is HIV Psychiatry he developed this interest during medical school when he helped co-author a chapter in Springer Nature's HIV Psychiatry a practical guide for clinicians which was then published in 2022 the chapter he co-authored dealt specifically with drug interactions and complications of anti- retrovirals and psychotropic medications and he also recently gave a grand rounds presentation to our program discussing HIV psychiatry in general after which I invited him on the show the interview was conducted on the 30th of January our discussion focuses on prep which consists of medications that effectively prevent HIV infections in at risk populations but we also discuss the history of HIV and AIDS disparities in treatment and other areas of concern for psychiatrists so without further Ado here's the interview well thank you for having me I'm Yan lindel I'm a Psychiatry pgy4 uh based out of Walter Reed and I'm here to talk about uh HIV prevention and psychiatry awesome and I'm Dr Oli you we we know each other we work together I'm just going to record here for everyone that we're speaking for ourselves here we're not speaking for anyone else we're not speaking for Walter reer the Department of Defense or our Residency program uh this is all for our own academic benefit tell me a little bit about how you got interested in this topic of course so I was lucky enough as a medical student to have a mentor who is very involved in the uh medication interactions between anti- retrovirals and psychiatric medications primarily in in um HIV treatment and she was working on a uh textbook and needed a co-author for a book chapter so I was uh eager to do something like that especially as a Capstone project as a medical student so that's how I got introduced to the topic and then I am going to be doing a consultation liaison Fellowship next year and HIV Psychiatry is very much considered in that wheelhouse so th those two things together motivated me to in investigate this topic nice HIV and Psychiatry I don't think people think of those two things together all the time like they think of HIV and they think of maybe infectious diseases or something like that uh Immunology what is psychiatry's role in treating people with HIV living with HIV right so there are a few manifestations of HIV and AIDS itself that are Neuropsychiatric in nature and that can definitely prompt the involvement of a psychiatrist especially if there are behavioral disturbances uh such as disinhibition that's often what a a psychiatrist might be called furthermore uh there is a higher incidence of HIV in patients with mental illness and then you also see the reverse as well that patients um with mental illness have higher rates of HIV so there is that connection there and then additionally um there are often a lot of questions if patients are on Ty retrovirals and also taking psychiatric medications so that that often requires a psychiatric consultation and then finally I would say that there are a lot of Psychosocial issues that come up if someone is diagnosed with HIV so that can prompt a psychiatric assessment as well and then I know that I said the last that was the last one but I think uh crucially for our talk today we are in the business of disease prevention as Physicians and there are many opportunities regardless of specialty to prevent the transmission of HIV so I think being aware of how to do that as a psychiatrist is very useful especially because we tend to have a better social history and awareness of our our patients uh behaviors outside of the office you talked a little bit about prevention of HIV and how that might we might be able to contribute to that especially because well we talk to people about Behavior right but so that what are the what are the ways that like a psychiatrist could help with HIV prevention in particular so I think the most critical thing that a psychiatrist can do to prevent HIV is identify uh the risk behaviors that are associated um with Contracting HIV and then pointing that person in the right direction to make sure that they can get the medications or the education that they need to prevent HIV transmission and how do you get that information do you get that information from everyone during your intake interviews or is it something that you you think maybe this person I need to go into a little more detail about things right so I think I would say that I'm getting better at taking a sexual history when doing an intake with the new patient I don't necessarily do that with my follow-up patients but I do think that this is an area that many Physicians are uncomfortable uh in exploring but sexual health is very important especially when it comes to mental health and well-being circling back to the initial question the concept of identifying who's eligible for for pre-exposure prophylaxis for example for HIV prevention like you're often tipped off based on the other symptoms or the characteristics that your patient may have so I think more often than not if I have a patient who identifies as a man who has sex with men so MSM I might be more likely to ask about uh pre-exposure prophylaxis or HIV risk I think if I'm doing a chart review of a patient that I'm seeing for a followup and notice that they were recently treated for an STI it might prompt me to ask them about condom use for example or their um exposure risk and then of course if we're treating patients with substance used issues you know screening to see if they're using uh injectable drugs or something else um that is typically another reason to to get involved I'm a little bit older than most of the other residents and I kind of remember in the 1980s when people first started talking about HIV and no one talked about HIV in the early 80s they all just used the word AIDS because that's how it kind of first presented when they saw patients who had already advanced into uh having an immune deficiency syndrome so the public was very scared and there were no treatments and a lot of people were dying and then I remember Magic Johnson he's like a retired basketball player he was uh one of the most famous people who contracted HIV um and he did it through very sexually promiscuous behaviors so he was open about that and that was the first time that the public as a whole really started to pay attention to anti-retroviral drugs because he started taking them and um so it was something where okay there's this sports star now who's taking anti- retrovi drugs and maybe having HIV is not a death sentence immediately so there's this huge huge change in how people viewed not just HIV itself but who can get HIV and uh whether or not how bad HIV is how it can be transmitted it took a few decades do you have any idea how people kind of view HIV now when you talk to people my experience is somewhat anecdotal as far as the perception of HIV there's definitely differences I I think when I consider how people view HIV I think you you consider the people who are at risk for getting HIV and then there are people who wouldn't consider themselves at risk but could be at risk um but consider themselves as outside of that that risk group and my perception is that there are different perceptions of risk when it comes to getting HIV so I think for example there are different adherence rates to prep and so I think that comes with the perception that this is something that's dangerous or something that's not dangerous or making a a risk benefit calculation in some ways maybe maybe we could start by talking about um what is prep how would you describe prep to one of your patients say they'd never heard of it before right so if I was meeting someone for the first time and I was explaining prep to them I would say prep is a medication that you take every day that helps protect you from getting HIV if you don't have it already who would you recommend prep for so I'm typically inclined to see what the CDC recommends when it comes to infectious disease primarily because it's not my um my main focus of practice and so when it comes to who prep is recommended for it's it's typically three categories so the first would be broad umbrella here is if you've had anal or vaginal sex in the past six months and you meet one of these criteria so the first being having a sexual partner with HIV next being not consistently using a condom and then third being having been diagnosed with a sexually transmitted disease in the past six months so that's the way the CDC breaks it Down based on sexual behavior but then they also recommend it in cases um where if you indirect substances and are sharing a needle with somebody else or have an injection partner who has HIV you just described who would qualify for prep if someone came to you and they said you know I'm a little bit concerned I don't have maybe they don't meet requirements for prep but they say I would like to take it do you think that's someone who would qualify for it the CDC recommends that anyone who requests prep should be considered for prep I haven't come across a situation where somebody asked for it without having any risk factors at all I have heard anecdotes of um some Physicians who may be at higher risk for um exposure to blood for example whether that be through surgery or procedures that may have considered using prep during while they practice but other than that I think the cdc's line is if you are requesting it you should consider it as a prescriber um and if someone starts on prep how long before they would be safe to continue whatever behaviors that they were that they were participating in before how long does it take to work I guess is is sort of the thing can they just go ahead and just keep on doing everything the way they did before is it best to kind of wait for a few days a few weeks that's a great question this was broken down for me you're right in wondering if crap takes a certain amount of time to become effective and so the way the CDC reports it is that if you are planning to have receptive anal sex you get maximum protection from HIV at about seven days of daily use so that's important because when patients uh start taking prep they need to understand that they need to use barrier methods for um HIV prevention while they are waiting for the prep to build up but then also important to understand is that for injection drug use or receptive vaginal sex that actually takes about 21 days so it's not the same as receptive anal sex and then there's no data uh for prep pill effectiveness for insertive anal sex or vaginal sex but the risk is assumed to be lower in those cases okay so there seems to be some things we just don't quite know um to be super safe you might wait 21 days um but in certain situations a week could be sufficient what what if someone told you well uh I I just have I do things on the weekend so I want to try to just take it uh Friday and then Friday Saturday Sunday and then come off of it is that an effective strategy there is a practice that is not approved called On Demand prep and the way that's been studied is a 211 schedule and essentially that means um so two to 24 hours prior to having sex or anticipating having sex you take two prep pills and then 24 hours later you take another pill and then 24 hours after that you take another pill this was studied in gay and bisexual men in preventing HIV and what the way it's been explained to me is that in those studies the 211 on demand method was used quite frequently so there was the question of is the frequency of this use similar to daily use so that's why it's not it's not quite clear and that's why it's not recommended by the CDC what is the difference between prep and and pep like if it postexposure uh prophylaxis say someone had uh sexual intercourse they find out the next day that the person they had intercourse with is HIV positive what is that different how does that different pep is something that postexposure prophylaxis is something that you would take if you were concerned that you were exposed to HIV and so as you and it's for emergency situations and it's not a substitute I'd say for prep and it's not the right choice for people who may be frequently exposed to HIV and it's definitely something that is considered in the first 72 hours especially if you're considered you're exposed to HIV and so I would say that this is different when it comes to practice in the sense that in the the system that I work in this is something that is best deal dealt with in the emergency room because there's a workup per se when it comes to cases such as sexual assault for example that involves um other social services and then um other services as well so typically these cases are best served in my hospital system uh in the emergency room so I'm trying to anticipate maybe one of my patients is on prep uh they have a friend that friend engages in some behaviors that are high-risk uh finds out that they had sex with someone who is HIV positive the person who's on prep decides to give that person their medication and say hey take this because they don't want to go to the emergeny room they're kind of scared are they are they is prep the same medication as as you would get or is it different it's not the same as prep so prep is either uh trada or dcoi and then there is an injectable medication as well um but the postexposure prophylaxis is it's a different combination I know people do share medications a lot too it's just one of those things that happens so maybe in the consent process be like you know if you do have friends also who are engaging in these behaviors it's not uh it's not sufficient to you know give this to them after an exposure you should encourage them to go to the emergency room and get a workup and get the appropriate medications as a psychiatrist what are the specific considerations that you have if you have someone who comes to you on prep or they're going to be you recommend to them that they see like infectious disease and get a potentially get a prescription for prep what are the considerations that you have like the top things you're thinking about so the first thing that I would be thinking about is medication interactions and typically the the patient panel that I have does not take that many medications and they're typically uh younger so the medication inter reactions are not always a concern but for my patients who are on mood stabilizers or antipsychotics I definitely need to reference whether or not those medications are interacting the next thing I would consider is adherence so I think we we know that in patients who are experiencing depression or low self-worth there can be decreased adherence to medications which of course increases the risk of being exposed or Contracting HIV in some cases I would be considered considering uh behaviors such as high-risk behavior in uh Mania for example or impulse uh disorders and that always has me counseling patients on the importance of adherance as well and then finally if my patients are experiencing a lot of guilt or shame or anxiety about being worked up for prep or testing for prep so um for your awareness Wess there is a standard prescriptive workup and regular testing intervals that patients go through if they're taking prep and if there's anxiety about being tested for HIV for example that could interfere with the adherence as well I was just thinking this really goes back to something we were talking about before but I had a patient who was on prep when uh he came to me and he he was on prep because uh him and his spouse were in an open relationship so they were they're geographically separated from each other one was living in a different place and so they just had just decided we can see other people we can have uh sex with other people and so they both went on prep and then uh they they had a conversation like okay we're going to become exclusive again we're moving back into so we're gonna not see other people how how long should they continue the prep do you have any idea so if the question is if they close the relationship and stop stop having sex outside of their relationship MH I think once they've both been tested for HIV and confirmed negative then they can stop taking the prep so long as they're both monogamous really the thing would be to to still confirm that neither of them have HIV maybe we could talk a little bit about the history of like the development of some of these medications anti- retrovirals now are used for far more than HIV the medications that were developed for HIV helped to open up the door for all sorts of treatments that we have for non- HIV things um hepatitis even covid we have medications now that probably owe their existence to the research that went into developing medications to treat HIV can you give a brief history of of once we found out that HIV existed how long did it take before we had effective medications so the period of time that the I think that we're talking about is the 1980s through the 1990s is when we first saw the the onset of AIDS and so I think like you mentioned it was kind of vague in in a sense that we didn't know what it was what it was it was uh essentially cases of previously young healthy homosexual men with capos saroma or um PCP pneumonia um popping up and that that really was confusing to the community AIDS first came onto the scene and 1981 it wasn't called AIDS at that time but this is uh essentially an identified illness that was interfering with the immune system of previously young and healthy people uh and that was manifesting with um unusual diseases such as kosu saroma and so this essentially led to commissions being set up by the CDC for example task force and it took several years to identify the different routes of transmission first it was blood transfusion and then perinatal transmission they identified later that female patients of men who were HIV positive could get HIV as well so there was there was some confusion in the the beginning definitely no treatments at that time and it was only in like the later half of the 1980s where there was essentially public education on uh what HIV and what AIDS were and of course I'm I learned this secondhand there was quite the impact of how people with HIV and AIDS were treated as you mentioned was was very poor there was a lot of confusion and fear and stigma out there some people credit Princess Diana actually for uh taking some photos with patients with AIDS uh shaking their hands without wearing gloves and that that really spoke to to what they were trying to dispel when it comes to transmission anti- retrovirals first came on the scene for HIV in 1996 so that's quite the time span so 1981 to 1996 and I think it's you can't really mention that timeline without crediting the advocacy for further research and development of treatments many people will will say that the disease was somewhat neglected because it didn't affect the communities with more power and influence and so it really took a lot of protest to to get the attention of decision makers to take initiative on this specifically having grown up during that time I remember um among the communities that I grew up in when I was younger that people called it uh a punishment they thought that uh HIV was created by God to punish people for sexual promiscuity particularly men who have sex with men I was taught this as a child you know or I overheard these conversations among the adults around and I I won't ever forget them and and it was there were even what are they call those the Saturday morning or Friday afternoon shows on TV where they would pick some social issue and they would make a little drama about it I remember one was about a kid who contracted HIV through a blood transfusion and at one point I guess he's using a knife at the counter he cuts his finger and the the mom has to treat treat the cut um but it's this in the in the show it was dramatized to such a big degree because there's the blood right there's the scary thing and and she just R run some water over it and did everything that a normal mom would do uh in that situation um but the music was ominous and it was really uh really something terrifying for people right and I I that reminds me of when we when I was in medical school we had a panel of um individual uals I think only one of them was diagnosed with HIV but she had gotten HIV through a blood transfusion and it was kind of framed as a I didn't deserve this the way that other people might have I had a lot of conflicting feelings about that U mostly in the sense that it's it's disease is not something that people earn or deserve so um I just I think that that framework and perception still persists yeah and I think especially with diseases that are associated with certain behaviors people uh tend to blame the person like oh you just if you had just not done that behavior you wouldn't have that disease so it's your fault that you have the disease when in fact like most of the time the behaviors they're talking about are behaviors that are normal human behaviors that everyone participates in right and you it's like telling people oh you just should never have sex with anyone because you know which is not going to happen what's that that c cognitive bias uh I think it's called attribution bias or something like that where uh if someone else is doing something and uh you you look at them as being morally wrong for for doing something or if they make a mistake it's their fault but if you make a mistake you don't attribute it to yourself you're just like oh well I was feeling bad that day or I just made a wrong decision but when it's someone else it's easier to attribute that to some flaw in their character it was 1996 you said when anti- retrovirals first came on the scene right and I I think there was within a two-year window there was a significant decrease in AIDS related deaths in the United States so there was quite the profound impact I think much with any development of new medications there and I wish I had more information on this but there is an access issue and an equity issue as far as who is at risk and who gets the treatments um so any strain on the system as far as Access to Health Care access to testing being able to afford medications those patterns that we we see today are exhibited when it comes to HIV care especially the adherence to prep for example is is studied quite thoroughly in the 2010s showing us that prescriptions of prep are more likely to be prescribed to white men who have sex with men compared to black or Latino men who have sex with men um despite there being um a disproportionate need in those communities so those racial disparities exist existed then and continue to exist today even with the availability of prevention methods uh there's a huge political uh issue sometimes because people view this like oh it's your fault for doing it they think that certain things that would prevent like clean needles that would prevent transmission is encouraging people one to do drugs and we we shouldn't be encouraging that behavior epidemiological studies show that interventions like that for for instance like have a huge impact on uh the rates of transmission not just of HIV but any kind of bloodborne illness that can be transmitted with a needle so there's a lot of barriers um B based on people's like moral values and the political influence in a particular place absolutely HIV is still a global pandemic right that's right yeah and it's been a global pandemic since well probably the late 70s we just didn't know about it until you know the early 80s what what are the disparities that exist now in terms of places where people have access to medications or prevented prevention methods so a lot of this is uh wrapped around a few things so the first is awareness of whether or not you're you have HIV so I think if I remember correctly it's just above 50% of people globally with HIV don't know that they have HIV and that number in the United States is around one and seven and so I think that may illustrate a few things it may illustrate access to care concerns or fears of um social stigma getting or just essentially fear of getting tested because there's concern that the test might be positive globally I would say that biggest Global Health Initiative for um HIV AIDS is the US president's emergency plan for AIDS relief that's also known as pepar and so this was brought up during the Bush Administration the the second one um to by second I mean second Bush well the first one didn't have a he right was reelected we're talking like 2201 time time frame okay um so this essentially was the the biggest Initiative for Global Health engagement and any specific disease by any country it was it was the largest contribution that had ever been made and so it didn't come without controversy so there was definitely a lens that only programs who are promoting abstinence and monogamy should get funding and so you you can see a few reviews of pepar and its Effectiveness uh you know down the road and people seem to to conclude that the absence only uh promotion globally was not as effective as it would have been if if it had been more holistic there are stories of essentially Generations or like an age group being wiped out in subsaharan Africa due to HIV AIDS I think typically people in their 40s so individuals who have you know younger kids who are also the backbone of the economy doing a lot of work that age group essentially was most likely to die at that time from AIDS related illness I wish I had had the uh population graph for you to show you the effect that uh this had on um the population uh age brackets as the years progress um but that was essentially devastating for so many people especially for children who were orphaned or left with one parent and then also terrible for the economy and you know that's not the focus of course the loss of life is is what's devastating yeah consequences right right it has it has um profound consequences yeah you know access to care continues to be an issue in the in the developing world and so hopefully uh pepar I guess I should I shouldn't uh plant any Flags but um it would be nice to know if pepar is going to be extended so that that Aid can continue to be provided otherwise we might see uh unintended consequences to to ending that program I don't want to like generalize like just say Africa and like that just mean everyone in Africa but uh as a as a continent statistically very young populations compared to places where we're having fewer children and we're have an aging population uh most uh countries in Africa have a very young population um and I I wonder if uh part of that demographic being the way it is had something to do with the p the HIV pandemic you know that's a that's a great question I I think I would be in a speculative space um to comment on that I I do think you're you know you're not wrong to to highlight subsaharan Africa my my understanding is that almost two-thirds of uh people living with HIV are in subsaharan Africa globally each Community is different and faces its uh unique challenges as far as um access to testing access to prevention and access to anti-retroviral through treatment um but I I I'm not exactly sure how the the age breakdown would have influenced the transmission do you know anything about what maybe the United Nations has done because you talked about the presidents I assume that's the United States right yes what about the United Nations itself it sounds like America has been a global leader on this that's definitely my my bias I'll say but the um so there's a program for HIV AIDS uh based out of the United Nations called un AIDs that emerged in 1994 their headquarters is in Geneva if you're ever interested in in visiting I don't have a thorough understanding of the way they organize things but you know the United Nations and the World Health Organization are are critical in managing these disease burdens so I'm hopeful that they are doing something incredible so kind of getting a little bit back to the role of a psychiatrist treating individuals who are either at risk for HIV infection uh or who have HIV uh and are on antiretrovirals we've we've you've discussed that we need to make sure that we're constantly uh checking on medication interactions in the most updated databases that we can find and then also treating certain conditions because the conditions themselves might uh contribute to for example lack of adherence to medication regimens that could worsen a person's condition I've seen signs and I've heard Uh u u equals U what does that mean exactly so U equals you is essentially a campaign that's meant to communicate that un so it stands for undetectable is untransmittable the evidence behind that is if your HIV viral load is undetectable on Laboratory Testing due to um taking anti retrovirals that means that it's virtually impossible for you to transmit the disease and so this is meant to destigmatize the illness and decrease fear around individuals who are living with HIV so if someone if if you are considering a relationship with someone who is HIV positive who has been taking HIV medications and is regularly getting tested and has been undetectable consistently then you are in a a very lowrisk group of Contracting HIV even though you're in a relationship with someone who's HIV positive right so I I think in those cases they still recommend that the HIV negative partner continues to take prep but they do the CDC does annotate that if you don't know your partner's uh viral load or they have a high viral load then that's definitely a case where you would take prep and then I think there's some shared decision- making that goes on um if your uh partner is undetectable yeah absolutely I imagine yeah if you if you're having sex with someone who is undetectable and you're on prep you probably have almost no chance of Contracting HIV right you are going into a consult liaison Fellowship after this and you mentioned earlier that the consult leison Psychiatry is often considered the uh subsp specialty of Psychiatry that deals the most with questions about prep or um anti-retroviral medications or just how to treat patients who are HIV positive in general um for psychiatric comorbidities why do you think the pcls service is the one that took on that mantle I would be speculating here as to why consult Psychiatry oversees the subdiscipline of HIV Psychiatry my understanding is that there is so much intersection between different organ systems medications and Neuropsychiatric presentations of AIDs that initially these cases were probably brought to consult psychiatrists in the hospital setting and that's probably where the the case reports and the expertise was was fostered and then it became a subdiscipline of the uh consult setting uh that that would be my my guess so it sounds like um potentially it was just a historical accident in a way uh the fact that so many people living with HIV were developing AIDS or other manifestations and were in the hospital for various reasons and that's where the consult liaison service does most of its work so they just sort of adopted that patient population early on just made history right I was glad that you brought this topic up because I'm going into Child and Adolescent Psychiatry as a fellowship and I know that the young people nowadays compared to my generation are much more Savvy uh about um sex sexually transmitted and diseases or infection HIV itself and I want to be able to give them like the most upto-date advice on you know what are the what are Best Practices if they're going to be sexually active and what puts them at risk versus what what doesn't and what they can do to protect themselves and prevent at least you know HIV anti-retroviral medication doesn't prevent other sexually transmitted uh infections necessarily so I think it will be very helpful for me to review this subject pretty regularly definitely and I I think that raises an important distinction you mentioned that um crap doesn't prevent the transmission of other sexually transmitted infections and I I'm exposed to a lot of I don't know how to put this I'm exposed to some media memes for example about essentially gay culture and there's this perception that now that prep is on the scene that it's it's taboo to use barrier protection or to use condoms and I think it's important to to understand that the purpose of wearing a condom is not to exclusively prevent HIV I think there's this idea that oh there are very limited consequences to Contracting any other sexually transmitted infection because I can treat those with antibiotics for example but we do know that there's treatment resistant gonorrhea and there are consequences to developing syphilis or chlamidia as well so I think it's important to keep to just know know that uh people seem to think that condoms are a bit go uh and that motivational interviewing if you will to to wearing them is is important especially um in people who are new to having sexual experiences you know younger people tend uh in general to not have the same fears as older folk they're they're more they're more afraid of some things because they have less experience but also with less experience they're not necessarily um have the level of consideration that they need to have for some of the behaviors they engage in I think that's a nice way to put it um so educating them in a very matter OFA way I hopeful hopefully it's helpful so you mentioned there there there has been changes in uh in the culture uh especially like of young gay men as the different generations of young gay men have grown up I can imagine being a young gay man in like 1992 um and seeing AG generation of um gay men who are now in their more more their middle age you know their 30s or 40s and uh so many of them who either had AIDS or had friends and lovers who died of AIDS um and just sort of decimated a whole generation of of people and then you know being and not having any options other than potentially like wearing condoms and now there are options and so so people are calculating their own risk differently is there a question no I'm just talking no you're you're absolutely right and I I think U one thing I'm um so there there is a uh a new long acting injectable for prep and that's something that I think we're quite familiar within Psychiatry but I'm not so sure if other disciplines are as comfortable with long acting injectable medications and so I'm curious to see if we see Healthcare models that do a One-Stop shop if you will where they have you get your STI testing you get your screening labs done you get your injection you meet with your provider and then you follow up again in two months um I'm I'd like to to see the the adherence results uh from that yeah that sounds far too efficient to ever be real are there any other issues surrounding HIV that you we haven't like discussed yet that you wanted to to talk about I think the point that I'd really like to hammer home is that we as psychiatrists are very much privileged to have longer appointments and more time to talk to our patients about their sexual health and well-being and so we should all be equipped to know what to do next if we think our patients are good candidates for pre-exposure or post-exposure prophylaxis so I think the only homework I would I would give on your on your podcast um is to familiarize yourself with what that next step looks like so that if you have someone in your office and you think they they meet that criteria you you know where to refer them and you're not uh asking all these questions about your system and how your system works uh in the moment I think a lot of times we're the first people that patients are open with in a lot of ways we we get the privilege of hearing people's secrets and and then and they may have been you know revealed things to us that they haven't revealed to their other Physicians absolutely and I think I think um as far as secrets and stigma and access to care if um if for one reason or another you don't want to have uh your pill bottles at home with your um prep an injection every few months is quite discreet in comparison yeah absolutely and don't have to remember ex you just all you have to remember is an appointment exactly I'd love to know more in the future about adherance rates to psychiatric medications in general I think we there were a few um comments during the grand rounds on this topic about how we encourage our patients to take their medications and there were some practical advice so having a pill calendar or even setting out two weeks worth of medications so that you know when it's time for refill but I I just don't know like I haven't reviewed the evidence that explained like this is what works with adherence and this is what doesn't work I think I had made a joke during the presentation about Fear Factor um and kind of right scaring your patients into to adherence but I I bet there are studies out there that says that doesn't work yeah um maybe not yeah probably well Fear Factor for other things like you know smok like you smoke you know the fear of getting cancer the fear of of uh COPD or something doesn't really tend to motivate smokers to quit smoking at least in that case uh one of the things that I do which I I don't know but I imagine probably increases um adherence to taking the medications every day as I talk about withdrawal symptoms with patients like if you stop taking this medication suddenly or you miss a few days you might experience these things and um at least for my more nervous patients they're probably far less likely to miss a dose just because they're they're a little bit concerned about the withdrawal I I will say that in the um in the health system that I work in there are some pretty strict guidelines with the frequency of appointments to get prep uh especially in the beginning you're seen for you're seen day one and then you're seen a month later and you only get one month of medication and I think they they kind of limit the supply of the medications that you get because people are so concerned about getting HIV that it encourages adherence to the testing that are required I'm sure that there is good evidence to support uh limiting the supply of medications to to link that to the necessary lab testing but I just I haven't seen the studies myself so what what you're saying is that in order to get more medication someone has to come in and actually get the labs that they need to confirmed that they're still HIV uh negative exactly so in some ways it it could be seen as a barrier because they have to come in more frequently but at the same time it's also part of the treatment you need to know uh if you are HIV positive or not because the medications that use for prep are not appropriate for someone who is HIV positive that's right and I think that raises the question of um access to prep and are you doing more harm than good by creating these barriers or is it better in the long run to have the wickets so that people get the medications that they need if they do convert to having HIV and also prevent uh potentially having more resistant HIV strains uh if you're treating them with the uh the prep medications instead of the instead of the more appropriate regimens that they give you once that they know you've been infected with HIV thank you yam for coming on it it's been a pleasure uh yeah the the opport Unity to listen to myself speak is um not one that I'm excited about you don't have to I can just I could just drop it just uh U no well uh thank you so much for for thinking of me for for this project um I hope that uh we learned a little bit about HIV prevention so I appreciate it yeah any anytime you find yourself uh excited about any other topic and you want to come back just let me know okay you'll regret that offer I'm sure potentially all right thanks Yan right thank you