New program breaks down HIV barriers with preventative treatment and a warm welcome

“Welcoming.” “Friendly.” “Awesome.” Those are the words 27-year-old Nadji Dawkins of Oakland uses to describe CRUSH, a pioneering program in Oakland promoting sexual health for young men of color who have sex with men that is now offering preventative HIV treatment.

It’s not the way people usually describe a medical clinic. But then, going to CRUSH isn’t like going in for a regular doctor’s appointment, which can be “cold,” Dawkins said. At a traditional clinic, people might greet you, do their jobs and get on with it. At CRUSH, Dawkins is welcomed with a smile, offered a snack and made to feel comfortable. “They’re actually interested in your life outside of just the visit,” he said. “They ask questions like, ‘Are you going to school?’… ‘How’s your job doing?’” CRUSH stands for Connecting Resources for Urban Sexual Health: the program targets 18- to 29-year-old men of color who are gay, bi or who have sex with other men, as well as transgender men who have sex with men and people who have HIV-positive partners.

One of the key elements CRUSH provides is access to Truvada, a drug marketed by Gilead Sciences of Foster City that is designed, if taken consistently, to prevent HIV from taking hold in the body, said nurse practitioner Jonathan Van Nuys of CRUSH. Truvada, a form of PrEP or pre-exposure prophylaxis, is a daily pill (an “antiviral”) used by those who are at risk of contracting HIV to avoid becoming infected. It is offered at CRUSH as part of a grant-funded research study through the California HIV/AIDS Research Program. The study is focused on learning how PrEP could best be accessed by young men who have sex with men in an urban clinic setting.The UC office of the President is also funding studies in Los Angeles and San Diego.

Dawkins first heard about Truvada over a year ago through the group Brothaz Connexion, a project run by the AIDS Project East Bay. A facilitator mentioned the medication, and Dawkins was intrigued. “I was kind of interested because I have a sexual life. What if I decide not to use a condom? It’s an option that I have,” he said. He was part of a 15-person pilot study in 2013 and went on to be one of the original clients at CRUSH, which started accepting patients in February.

When he was first prescribed the medication, Dawkins learned that it’s important to take Truvada every day in order for it to be effective: it takes about 7 days to build to a protective level in a patient’s system. He said he has missed a pill on a few occasions, but he said the doctors don’t recommend “doubling up” or taking two pills the next day. Rather, if he misses, he takes his pill as normal the following day. “There’s a high level of the drug in my bloodstream,” he said.

The Centers for Disease Control requires people on Truvada to take HIV tests every three months, but CRUSH requires study participants to come back after their first month and again after two months to take HIV tests and to check in with staff to make sure they aren’t having trouble with the daily regimen.

On September 5, about 81 people were enrolled in CRUSH and 39 of them were taking Truvada. But only three weeks later, enrollment was up past 100 and Van Nuys estimated that nearly 50 people had been prescribed Truvada. “It’s kind of rising weekly,” he said, estimating that between three and five people start the drug each week. The goal is to have 400 people enrolled in the program by the end of the study, which ends in March 2017.

Van Nuys said the drug is “breaking down barriers” between HIV positive and negative people. Taking a daily preventive pill makes people more empathetic toward those who take daily medication for HIV, he said. “There’s been a division for a long time, and I think a lot of that is motivated by fear and silence. So anything that breaks down either of those things can help,” he said.

CRUSH, which is housed on the second floor of the Alta Bates Summit Medical Center in Oakland, is part of the East Bay Aids Center and was designed to be an extension of the Downtown Youth Clinic. CRUSH is focused on sexual health as a whole and works with clients to develop personalized sexual health plans that could include using condoms, getting tested regularly or taking Truvada. The program also offers testing, diagnosis and treatment for sexually-transmitted infections, care for HIV-positive young people and post-exposure prophylaxis, which consists of 28 days of medication for those who have been exposed to HIV within the last 72 hours.

The Downtown Youth Clinic was formed in 1997 to address rising numbers of HIV-positive young people, primarily men who have sex with men. It was designed to remove barriers to care: patients can walk in anytime and aren’t penalized for missed appointments. Peer mentors have relationships with clients who are made to feel welcome. CRUSH extends this model of care to HIV-negative young people. Although CRUSH mostly serves people in Alameda and Contra Costa counties, “we really accept people from anywhere,” Van Nuys said.

Truvada was approved by the U.S. Food and Drug Administration in 2012. The Centers for Disease Control and the World Health Organization have endorsed PrEP to be used alongside condoms, especially for men who have sex with men. But Van Nuys acknowledged that Truvada is controversial. One criticism is that the drug isn’t always effective, although, Van Nuys said, low efficacy is linked to poor adherence to the daily pill regimen. The most recent study of PrEP—the iPreEX Ole study, presented by Dr. Robert M. Grant of the University of California, San Francisco, at the 20th International AIDS Conference in July—showed that PrEP had no significant efficacy for people who took fewer than two doses a week. However, the efficacy was 84 percent in people who took 2-3 doses a week and 100 percent efficacy in people taking at least four doses a week. “If someone doesn’t take it, it’s not going to work,” Van Nuys said.

Another criticism is that it could encourage people to stop using condoms, Van Nuys said. “Condoms had been all we had, really, to prevent HIV for a long time. So I think it’s scary for people, understandably so, to have anything that dilutes that message,” he said.

Dawkins said it’s important that people know Truvada isn’t a cure or a vaccine but a preventative measure. “As long as you follow the instructions, you’ll be good,” he said. While he said it’s a hassle to take a pill every day, “people can do it.”

“It’s a matter of really making it a habit and putting it in your head, ‘I’ve got to take this pill,’” he said.

Dawkins said being on Truvada has made him more aware of his sexual health. Before he began dating his current boyfriend, he started using condoms more often and would schedule appointments to get checked for sexually-transmitted diseases. “There’s other things to get besides HIV,” he said.

Dawkins’ 25-year-old boyfriend Darrell Jackson is now also part of the study; he travels across the bay from San Francisco for CRUSH’s services. He started Truvada about two weeks ago. He first heard about the drug through the DREAAM (Determined to Respect and Encourage African American Men) Project, a community organization for young, gay, bi or trans African American men and women run by the San Francisco AIDS Foundation. The pair have been together since July; they met at the San Francisco LGBT Community Center while attending a poetry slam. Jackson said that, at CRUSH, he’s treated “like a person.” He likes the fact that “they don’t hold their title over your head. They just make you feel comfortable,” he said.

CRUSH retention care coordinator Alfonso LaCorte said one goal of the grant-funded study is to determine what interventions keep young people coming back for care.  “We’re starting from the ground up, basically figuring out what works,” he said. The organization makes it as easy as possible to attend, even providing clients with parking passes for the garage across the street from the hospital and taxi vouchers. Those that take BART can get free shuttle rides from MacArthur to the hospital.

Communication can be a significant barrier, he said. Young people can’t always pay their cell phone bills, so CRUSH has found email and text messages to be a good way to contact clients. “Sometimes they’re not at leisure to pick up a phone and call us,” he said, so “text message has been a big thing for us.”

LaCorte said he assures clients everything will be kept confidential and that the more a client shares the more he can help them. The practice is working. “They feel like we know where they’re coming from,” he said. “They’re more able to express what they’re feeling and what their concerns are.”

The clinic, located at 3100 Summit St. in Oakland, is open Monday, Tuesday, Thursday and Friday from 9 a.m. until 5 p.m. To make an appointment, call 510-863-0021 or go to www.crush510.org. Eighteen to 29 year old men who have sex with men, transgender people who have sex with men, or those living with an HIV positive partner are eligible to receive services at CRUSH.