December 12, 2013
"Tell me what you want to have done," the staid-faced nurse practitioner blurted out after I sat down in her office. It wasn't exactly the friendliest way to begin a patient interaction, but it was nonetheless music to my gay ears. For six years, I'd been coming to this very student health clinic at the university I attend for graduate school, trying desperately to get screened for sexually transmitted infections. And for six years, doctors have treated me like some kind of oddity they didn't want to touch with a ten-foot pole. Frustrated, I finally decided to specifically request an appointment with a nurse practitioner instead of a doctor.
I sat making a mental checklist for a second before prattling off my Christmas wish list. "Well, I need a blood draw for syphilis, RNA test for HIV, a urine test for gonorrhea and chlamydia, NAAT swab for pharyngeal gonorrhea, and a NAAT swab for rectal gonorrhea and chlamydia." Needless to say, I had done my homework. The nurse looked a bit surprised, but nonetheless turned to her computer to enter in all the lab requests. After a phone call to the lab and some serious computer sleuthing, she looked flummoxed. "The computer will only let me choose cervix or urogenital as the site for the NAAT swab." I leaned in with a wry smile: "Just tell the lab it's from my cervix." I thought maybe she would twerk the system for me. Alas, she said she'd have to do some research into the matter. Come back another day for the swabs, she said.
While I didn't get what I wanted that day, I left hopeful that she would triumph over the bureaucracy and finally get me screened. The truth is that I haven't been tested for gonorrhea or chlamydia in my throat or ass for years now. The few times when I suspected I had been infected, I got my hands on antibiotics through friends or family members and self-treated with guidance from websites. For many gay men with clueless providers, that's the unfortunate reality in which we live. So when the prospect of actually getting properly tested seemed to be materializing, I was genuinely excited.
The nurse finally got back to me after six weeks, only to tell me the administration refused to allow the test because it wasn't Food and Drug Administration approved for pharyngeal or rectal screening. "We could run a culture," she offered. But she and I both knew that cultures are piss-poor tools for gonorrhea and chlamydia screening. Unlike newer technologies such as NAAT tests, which are much more accurate, cultures get it right less than half the time. I told her I'd rather flip a coin.
Intent on getting the care I need and deserve, I turned again to my PrEP doctor, who works out of the local hospital. I thought he might be able to finagle the system on my behalf. His response was even more disappointing: "Well, you know, there generally aren't many complications for men. The only real concern is possibly spreading it around." I sat steaming, wondering to myself if my doctor actually had a functioning brain. I was on PrEP, for fuck's sake. Did he think I was just going around town shaking hands with other gay men? "We could do a urine analysis," he offered. I pursed my lips. "If I'm going to get gonorrhea or chlamydia, the last place it's going to be is in my dick. Most of my partners don't even touch it." That wasn't exactly true, but I wanted to make a point.
If you're lucky enough to live in a city like San Francisco, you have the advantage of access to skilled, knowledgeable, and nonjudgmental health clinics like Magnet, a project of the San Francisco AIDS Foundation. You can waltz in on any given day, confident that you'll be treated like a grown adult with legitimate health needs. But if you venture outside of these urban meccas, you're likely to find yourself face to face with ignorant and unhelpful providers who are more likely to judge you than offer you the appropriate sexual health services.
Before you imagine that the problem lies in the lack of a published standard of care, the Centers for Disease Control and Prevention publishes STI treatment guidelines that are updated every few years. The most recent, published in 2010, includes crystal-clear guidelines for men who have sex with men:
I sent this document to my provider and to the director of the student health clinic, but they refused to change course. They were sticking to their original story: No FDA approval, no test. While it is technically true that the FDA has not approved NAAT tests for rectal and pharyngeal swabs, the tests are used widely by clinics that serve gay men. It's about priorities, and gay men's health isn't even remotely at the top of that list.
In order to understand what 21st-century sexual health screening for gay men could look like, I asked the director of Magnet, Steve Gibson, about their standard of care. "Culturally competent STI screening for gay men should basically mean, if you use it, you should check it: your butt, your throat, and your dick! Many gay men coming in to Magnet know a great deal about HIV but very little about other STIs. We do a lot of basic education about how STIs can be spread and treated." A lot of times, though, you have to ask for what you need. For example, Magnet customers have told Gibson that Kaiser Permanente does not routinely test them for rectal and pharyngeal gonorrhea and chlamydia unless they specifically request it.
When it comes to HIV testing, Magnet has put together a state-of-the-art program. Like many clinics, they use a rapid HIV test, the Clearview HIV 1/2 STAT-PAK Test, for the initial screen. For those men whose first test was "reactive" (positive), a second rapid test, this time the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (the same one you can buy over the counter for about $40), is performed to verify HIV infection. This allows Magnet to promptly begin linking newly diagnosed individuals to care.
But antibody tests can't pick up recent infections. While RNA tests can detect HIV in a person's blood within 9 to 11 days after the person is infected, they're expensive. In my case, health insurance covers the cost. But public health clinics generally can't foot the bill. In order to get around this hurdle, Magnet partners with the San Francisco Department of Public Health laboratory to conduct pooled HIV RNA testing: Magnet sends individual specimens to the lab, the lab combines samples from each (ten at a time) and runs a single test, and if the result is reactive, the lab then tests every individual specimen to find which ones contain HIV RNA. Creativity for the win!
You may have heard recently that a new rapid HIV test was FDA-approved that actually can detect recent HIV infections. This test, The Determine HIV 1/2 Antigen/Antibody Combo, tests for both antigens and antibodies and thus is much better at detecting recent infections. But while it's approved for laboratory settings, it's not yet approved for community-based sites like Magnet. COME ON, ALREADY!
The truth is that the FDA probably has about zero pressure on it to approve the new HIV test for use in community clinics or to approve the use of NAAT tests for rectal and pharyngeal gonorrhea and chlamydia screening. Why? The sad reality is that few organizations are out there actively organizing on behalf of gay men's health. LGBT organizations don't prioritize it. HIV organizations are often too scared about losing even more funding to raise any hell with government agencies. Although glimmering signs of its resurgence have appeared recently, ACT UP today is more a subject for documentaries than a real force in current politics.
But while ACT UP may be a shadow of its former self, its lessons live on. In the words of Steve Gibson, "We all have a right to the best possible, most relevant and accurate information about our health without bias or prejudice from medical or public health providers." And as we all know, rights don't magically translate into reality. Nobody is going to give gay men the health care we need without a fight. Is your health clinic offering NAAT tests for gonorrhea and chlamydia? No? Ask why. Demand they start doing it. Does your doctor know about PrEP? Ask. What's your state health department's stance on sexual health screening for gay men? Do they have one? If we want answers, we're going to have to start asking questions and raising hell.
What's your experience like at your local health clinic? Share your stories in the comments or, as always, shoot me an email at firstname.lastname@example.org.
Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade. He previously published a 19-part series documenting his experiences on pre-exposure prophylaxis (PrEP), "My Life on PrEP," for Positive Frontiers magazine, which was picked up by Manhunt, translated into French, and widely read in the HIV prevention world. He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV.