1/
A man came into our clinic to start #PrEP.

Almost 50 years old. Well educated. HIV negative.

In a romantic and sexual partnership with another man, also HIV negative.
No other sexual partners.
Doesn't smoke, drink, or use drugs.

Reports using condoms 100% of the time.
2/
Tops most of the time with anal sex.
Sometimes bottoms.
But mostly enjoys oral sex and foreplay.

We discussed PrEP. Its effectiveness. Possible side effects. Pros and cons. Insurance coverage.

Many would ask "Why give this man PrEP? He's not 'high risk'."
3/
The answer is simple.

PrEP is a #sexualhealth program. It's not simply for those whom medical providers deem to be "high risk."

He gets to choose the combination of #HIV prevention methods that are best for his sexual health.

If he feels he needs it, I trust him.

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More from @DMalebranche

7 Jun
1/
I've been seeing a patient living with #HIV who has had right hip pain for 5 months.

He is a 33 year old Black man who hobbles around like he's 90.

He just lost his job.

The pain was so great he couldn't sleep at night and was dozing off during his shift.
2/
No one explained to him what was going on. He got an x-ray at an ER five months ago.

He understood that he had a "ruptured" hip.

Doctors who have seen him have only given him ibuprofen and Aleve for the pain.

Both don't touch it.

He cried during our first office visit.
3/
He could barely get up on the exam room table without excruciating pain.

I couldn't rotate his right hip due to the discomfort it caused him.

We agreed to try a low dose opiate and muscle relaxants as needed.

Our clinic would request the medical records from his ER visit.
Read 10 tweets
4 Jun
1/ "Undetectable = Untransmittable" can be an empowering message for people living with #HIV.

That said, we don't explain to patients that the studies leading to that slogan defined "undetectable" as a viral load less than 200.

Not less than 20, which is the current standard.
2/ So when people are stable on their HIV medications and see their viral load go up to 60, or 100, or 120...

Listen to and address the anxiety they feel, thinking they are not "undetectable" anymore.

Reassure them that they are and you will follow things closely.
3/
As clinicians, we need to do a better job explaining that these small increases in HIV viral load are called "blips."

Blips are common.

A. Doesn't mean the medications have stopped working.
B.. Doesn't always mean you are now "immune" to the meds.

catie.ca/en/positivesid…
Read 6 tweets
18 Apr
I had to send a 26 year old patient to the hospital yesterday after a telehealth visit.

He is living with #HIV

Had lymphoma 5 years ago requiring surgery and chemo

Has syphilis titers that have stayed elevated for 2 years, even after outpatient penicillin treatment.
1/
Now is having fevers, nightsweats, headaches, blurry vision, and unintentional 10 pound weight loss in two weeks.

His T cell count dropped from 200 to 100, even though he is taking his HIV meds and has an undetectable viral load.

I gave him my cell number just in case.
2/
The admitting hospitalist reached out to me this morning.

Him: "Your patient gave me your number. I guess he wanted me to call you with updates."

Me: "No, I gave him my cell phone so you could call me if you needed more information for your clinical decision-making."
3/
Read 7 tweets
25 Mar
Did a follow up call with a patient this morning. Gave her her #HIV lab results:

- T cell count over 1000
- Viral load undetectable

No reaction. It was expected. We spoke about other referrals before concluding .

"Anything else I can help you with?" I asked.

She paused.
1/
"Doc, I have a question, but it's more personal."

"Shoot," I responded, unsure where this was going.

"Do you know anyone in the medical field who is living with HIV? Before my diagnosis I wanted to go into the field but I didn't think I could after that."

My turn to pause.
2/
"You're speaking to one," I said.

I could feel the weight lift from her shoulders through the phone.

"Living with HIV doesn't mean you can't work in the medical field," I continued. "There are many people who are HIV positive and work as doctors, nurses, every position."
3/
Read 5 tweets
6 Mar
A young Black man has been living with #HIV for 4 years.

He is adherent with his meds. The lab report shows he has been undetectable since he started treatment.

He works 16-hour days in a factory and is seen at a busy urban HIV clinic.

He has private insurance.
1/
His last in-person visit with the clinic was in January 2020, right before the #COVID19 pandemic shut the world down.

All was well during that appointment.

His doctor continued his prescription with a year's supply of refills.
2/
He is scheduled a 3 month follow-up telemedicine appointment during the #COVID19 pandemic.

All continues to be well at that visit.

It's April. Flowers are beginning to bloom.

He is given another telemedicine appointment 3 months later.

He misses that one.
3/
Read 10 tweets
21 Nov 20
1/
I went to a local @cvspharmacy today to get my second shot of the Shingrix vaccination.

This is the vaccine that helps protect people over 50 years old from getting the painful reactivation of the childhood chickenpox virus.

Also known as shingles.
2/
The pharmacist was kind. Applied a discount to offset the cost. Gave me the obligatory medical information and consent form to sign.

I did.

He "gently agitated" the vaccine mix in front of me.

To my surprise he came around the counter to give me the shot.
3/
"Which arm?" he asked.

I took my left out of my jacket.

As I turned away from him, I noticed a Black woman staring at me.

Her eyes wide in a mix of horror and surprise.

She was picking up her medications, but got distracted.

I knew exactly what she was thinking.
Read 8 tweets

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