Implementing HIV PrEP in Mental Health Care Podcast: Your Questions Answered

This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.

Dr. Glenn Treisman (Johns Hopkins Hospital): Hello, everybody. I'm Glenn Treisman. This is my colleague, Dr. Marc Fishman.

We've been working together for many years. Dr. Fishman runs a very large substance abuse treatment program here in Maryland that has several sites and has been one of the world's experts on substance abuse disorders in adolescents and how to prevent them. I run the Johns Hopkins AIDS Psychiatry Service, which is a service that provides psychiatric care for patients infected with HIV.

Dr. Fishman and I have been doing that work together since the late 80s. And we've seen thousands of patient visits over the years. We treat patients who have psychiatric disorders. The goal of today's presentation is to try to get your questions answered about implementing pre-exposure prophylaxis in mental healthcare settings. That's the goal of today's meeting.

But we'll talk to you some about what we know about this subject and discuss that a little bit today. PrEP is remarkably easy to use. It is virtually 100% effective in sexual situations. So we want people who need PrEP to take PrEP.

The discovery of antiviral drugs in the mid-90s that you can give people a cocktail of drugs and prevent HIV from replicating in the human body was a huge breakthrough. We fairly quickly discovered that even two of the drugs that we use for HIV treatment given together are effectively able to block people from getting infected with HIV.

How You Can Help Prevent HIV

So I wanted to talk to the audience briefly about the fact that mentally ill people are at increased risk for getting HIV and people with chronic mental illness actually have higher risk sex. So they're at increased risk for getting infected. And we've been trying to encourage people to learn about preventing infection with PrEP.

And we've had some previous presentations that you could look at to get more details about what we do and why we do it.

Mental Health Conditions Increase the Need for PrEP

But people with mental health conditions are more likely to acquire HIV, less likely to get tested, less likely to get care, less likely to get undetectable viral loads and more likely to die than people who don't have mental health issues.

And that's why part of the reason why we focus on them trying to get them into prevention programs and get them treated PrEP provision in people where have mental health clinics. It has facilitated improved persistence that is patients who get cared for in a more holistic way are more likely to stick with their care, even their psychiatric care.

So we want people to feel like we're seeing the whole person and not just their mental illness.

Mental Health Professionals’ Responsibility to Recommend PrEP

I believe that if you have a patient, you have a certain responsibility to try to prevent them from getting sicker. People talk about whether or not you should talk to your patients, for instance, about smoking cigarettes.

Marc runs a big substance abuse program and a lot of the patients smoke cigarettes.

Do you talk to people about smoking, Marc?

Dr. Fishman: No, it's a great analogy. And the idea, which in my mind is an old-fashioned, outmoded idea that that's not in our wheelhouse. It's not as important as getting them off fentanyl, but you can only do one thing at a time. Patients have limited bandwidth. Why would you deprive them of their last little pleasure? It's not good for recovery to overload people with too many goals. You know, these are the kinds of things people say. But the notion that people are going to die more often of cigarette smoke. For example, we bemoan that there are 75,000 deaths a year from opioid overdoses. Well, there's 400,000 deaths a year from tobacco-related mortality. And the same thing goes with schizophrenia. More people with schizophrenia die of smoking-related illness than do of suicide. So thinking holistically, thinking about the myth busting that we need to do to be full doctors and think about all of these elements in health, we should be talking about risks, educating patients about risk, talking to them about risk modification, and where we have good treatments, including pharmacological treatments. Again, the analogy to cigarette smoking, where we have great pharmacological treatments. It's imperative, I think, for us to broaden our scope, broaden our wheelhouse.

Dr. Treisman: The second thing is that our patients see us more than they see their primary doctors. And we see patients fairly frequently in the HIV clinic. Some of them come every two weeks. Some of them come every month. Some of them come weekly and gives us an opportunity to know the patients well and to be able to work with them on lifestyle changes. Many of the drugs we use cause weight gain and can make diabetes significantly worse.

And we've gotten very good at trying to cope with that by using GLP-1 drugs and other things. But certainly even 20 years ago, you and I were advocating for people to test hemoglobin A1C in all patients on antipsychotics and on certain other medications where weight gain is an issue.

Dr. Fishman: No. It's right. And when I think of talking to trainees and supervising clinicians in my system, asking psychiatric practitioners to expand scope to prescribe metformin along with antipsychotics to prevent weight gain. It's that same kind of issue. Be holistic. Think a little bit about broadening your wheelhouse and expanding your tool chest.

Dr. Treisman: Yeah. And then the issue of sexual health. We still have an epidemic in this country of other sexually transmitted diseases. And when I wrote my first paper, I was looking in the Journal of Sexually Transmitted Diseases.

Back then it was called venereology. And in the 1920s and 30s people noted that psychiatrically ill people were more likely to get venereal disease. And so it's a long-standing issue that our patients need to be talked to about sexual vulnerabilities and sexually transmitted diseases.

Dr. Fishman: And, you know, that is so important and sometimes difficult and awkward for practitioners.

So a plug for practicing and learning language to put patients at ease and engage them and talk about sexual practices and their sexual lives and their sexual fulfilment and frustrations and their sexual risk behaviors in a way that will help guide them about risk reduction and being comfortable with asking those questions. Because if we don't ask, they're going to be too embarrassed to tell us spontaneously a lot of the times.

Dr. Treisman: Yeah.

And I can't tell you how many patients over the years have come in with sexually transmitted diseases and we were the first people to see them and teaching residents to go ahead and take the history and get them the necessary care is very useful.

Waiting to treat chlamydia can be disastrous for patients who get aggressive pelvic inflammatory disease if they're not treated.

Discussion: Why Mental Health HCPs Should Offer PrEP

Dr. Fishman: Never mind waiting to treat primary and secondary syphilis before it comes tertiary.

Dr. Treisman: Exactly. So the discussion is why should mental health providers offer PrEP? Which types of people are most likely to benefit from PrEP? And those are people who are sexually active and particularly people where their sexual activity involves drug use are at much higher risk. And what's the best way to integrate a discussion of sexual health into the mental health visit? And how do you discuss PrEP with people? How do you tell them about it? And how should you talk about the benefits of PrEP?

Dr. Fishman: And just a quick plug, although sexual risk behavior these days is a more frequent risk factor, we can't forget injection drug use as a risk factor. And certainly that's a population that many of us care for and needs to be screened and talk about risk behavior and recommended and prescribed PrEP.

Dr. Treisman: And then the conversation of normalizing PrEP and trying to reduce HIV stigma. Patients see me in an HIV clinic, and many years ago we were terribly worried about having an HIV clinic because if you go to the HIV clinic, it means you have HIV. And would people be so stigmatized that they wouldn't go to the clinic? We haven't had a problem with that in our clinic.

We always have more patients than we can take care of. But there is a huge stigma associated with having HIV. It's still quite stigmatizing. And trying to talk about the fact that it's no different than other sexually transmitted diseases now and although it's a lifetime disease, it's a treatable disease and doesn't shorten your lifespan.

And then nowadays the idea that if you have HIV, if you're undetectable, you don't transmit and you should be considered essentially a normal person is a big issue.

Who Should Be Considered for PrEP?

Who should be considered for PrEP? The CDC recommendation is that all sexually active adults and adolescents should be educated about PrEP for the prevention of HIV acquisition.

Recently had a very interesting case, a case I've been seeing for years, guy with straightforward major depression who has marital issues and finally admitted to me that he's been going to massage parlors where he gets a sexual release at the end of his massages. He hadn't ever thought about the possibility of getting a sexually transmitted disease in that environment. And I talked to him frankly about his behavior and the fact that he is at very significant risk. And we talked about PrEP, gonorrhea, syphilis and other sexually transmitted diseases that he was shocked to learn about. And maybe it will modify his behavior, but certainly the conversation is designed to modify his behavior.

Strategies for Integrating PrEP Into Mental Health Care

Dr. Fishman: Yeah. No, it's very important. What you just described reminds me of a case of a man with methamphetamine use and high-risk sex with men and a pattern of mood instability, which my hypothesis was reflected bipolar disorder, at least bipolar disorder type II. And I was not able to persuade him of my hypothesis of a mood disorder or get him to take mood stabilizers. But I was able to persuade him to take PrEP and prescribe PrEP. And that was a good entrée for ongoing conversation, not just about preventing risk of HIV transmission with the pharmacological treatment that is PrEP, but also about modifying his sexual risk behavior as it was so intertwined with the impairment that he got from methamphetamine use. And he had trouble seeing that. “Oh, well, it's just I'm having sex with the wrong people. If only I could find the right people.” “Well, how's that working for you?” You know, those kinds of conversations for the risk modification over time.

And I think that giving people tools helps with engagement and further some of these other longer term conversations about risk behavior modification.

Maybe someday I'll get him to take lithium, who knows. But that would be part of that ongoing engagement.

Dr. Treisman: Yes. And I think it goes back to the idea that the more we engage people, the more engaged they will stay with us.

Dr. Fishman: Yes.

Dr. Treisman: And so providing medical care is often an entrée into providing mental health care, even for people who initially are very uncomfortable with the idea of having a mental illness.

So identifying patients at risk is the first step, talking about PrEP and initiating it. And then referring to primary care, if people need it, and then multidisciplinary care to monitor and support adherence to PrEP. So there's a number of different ways to do PrEP and one is pills and one is injectable drugs, long-acting drugs, of which there are a couple of options now.

Discussion: Who Is Eligible for PrEP and How to Start Prescribing

And then you ask the question, who's eligible for PrEP and how do you start prescribing it? Can you start it the first day you see people? You can. You should test people because PrEP only has two of the three drugs that are present in most people's cocktail of HIV treatment. So if they're already infected, you'll want to broaden their PrEP into coverage that will cover them completely.

Dr. Fishman: So that's an important decision point.

PrEP is great. For two-drug, PrEP is great for prevention, but not sufficient for viral suppression once a person is infected.

Dr. Treisman: How do you initially start PrEP conversation with your patients? Are patients normally responsive, or caught off guard in the mental health clinic?

Dr. Fishman: That's a great question.

Dr. Treisman: Great question. When we first see patients, we take a very comprehensive history including sexual history. And ask people about their relationships, their sexual experiences, their sexual problems, things that might be a big problem for them in terms of their day to day lives, but also risk behaviors. And because it's part of the kind of standard conversation, we get to PrEP fairly easily from that when we talk to people about what they are doing.

So Dr. Fishman mentioned his methamphetamine patient. Most of the patients who use methamphetamine in our clinic have high-risk sex as a major factor. And they're already on HIV medicines. But it leads you to know that people are using stimulants are at very high risk. Stimulants seem to increase impulsive, high-risk sexual behaviors out of proportion to other things.

We do see patients who use sex as part of their complicated heroin fentanyl lifestyle. Sex is part of their deal. And talking to those people, very important to find out what risks they have from that behavior and who they're having sex with, and what we can do to try to help protect them.

Dr. Fishman: And one of the ways that people will not be caught off guard, as you're mentioning, Dr. Treisman, is that you've already been having conversations with them about a wide variety of personal and intimate behaviors. They know that you're doing so not out of judgement, but out of concern and wanting to get to know them as a whole person, so it won't be out of the blue. You've already asked them about sexual things.

It may be more than their other physicians have, but that's what we do as mental health professionals. And so it won't be that they're caught off guard and it won't be that they feel judged because you're doing it from a point of view of caring and health promotion and out of concern and wanting to know these things in a broad way, not just about PrEP.

Dr. Treisman: When Dr. Fishman and I started this work back in the 80s, there was concern that because we spent an hour with a patient, the amount of burden of seeing psychiatry would be too overwhelming for patients coming to the HIV clinic. And what we found is when we did a full hour evaluation on every patient that their next visit show rate was actually increased. That is, people were more likely to come back, and we asked them why. They said, well, they're really interested in the whole person in this clinic. They asked all these questions about my life. And I think that that enhances the relationship rather than…

Dr. Fishman: So true. And that's been – we had that paper, but it's also been demonstrated again and again that this so-called assessment reactivity is a real phenomenon that patients, both are engaged over being assessed in a comprehensive way, and they respond to it as an intervention because it brings certain risks under the spotlight of your understanding, their understanding and of concern.

So even just the assessment is in itself the beginning of an intervention.

Dr. Treisman: And then one of the questions on here is, what about long-acting antiretrovirals that you inject? So these long-acting antivirals can last months for PrEP and can prevent HIV transmission for months. But as the blood level falls,

people get more and more likely to get infected if they're not getting regular injections. So you want people – if they're going to do this, you want them to do it. You can inject those drugs in your clinic, but you can also have pharmacies inject them. And a lot of pharmacies now will inject cabotegravir/lenacapavir in pharmaceutical settings. It's a financial boon to the pharmacy and great for the patients.

Dr. Fishman: And it helps.

Dr. Treisman: It helps you because you don't always have a nurse who's willing to give IM injections. I don't know. Do you have somebody in your setting, Marc, that you could give…

Dr. Fishman: We do. Most of our—not all, but most of our settings have nurses. Some of our purely outpatient shops don't, but many of our outpatient shops are connected to bed-based care where there are nurses. So we can give injections.

And listen, as psychiatrists and mental health professionals, we are big advocates across multiple domains

and multiple pharmacotherapeutics for long-acting injectable medications, which have huge adherence advantages. We are of the mind that longer is better. And that pertains to long-acting antipsychotics, where adherence clearly goes up. We don't wait necessarily for people to be non-adherence. Non-adherence is the rule rather than the exception. It's really hard to take medicines every day for long, long periods of time.

Long-acting medications for opioid use disorder like extended-release buprenorphine and extended-release naltrexone. Anyway, across the board, these are good strategies to have in your tool chest. And if you don't have nurses, the idea that Safeway and other chains are now introducing these pharmacy injection supports, I think that's good news for patients.

Dr. Treisman: Yeah. So one of the things about patients resistance to long-acting drugs.

In psychiatry, I don't know what your experience is. Mine is that patients are very resistant initially to get long-acting antipsychotics.

Dr. Fishman: There’s a persuasion.

Dr. Treisman: Now what's interesting is they've been much less resistant to taking long-acting antivirals.

Dr. Fishman: Oh, interesting.

Dr. Treisman: So we haven't had to push people to take long-acting antivirals. Many of them come asking for monthly or every two months or six months injections that are preventative of HIV infection.

Dr. Fishman: Yeah.

Dr. Treisman: And many of the people on HIV treatments are eager to take, try out these long-acting drugs.

Dr. Fishman: That's great.

Dr. Treisman: So they've had better acceptance than neuroleptics tend to have because they have – I think they have way less side effects overall. And neuroleptics have a burdensome set of side effects.

Dr. Fishman: Although – I totally agree with you. Neuroleptics in general have a high side effect profile and patients sometimes struggle, but, you know, the smoother lower blood level delivery over a month has generally a more favorable side effect profile than the sawtooth peak/trough, peak/trough side-effect profile of orals because in general, side effects follow peak blood levels. And so if you can smooth out the pharmacokinetic curve, patients generally tolerate them better.

But you got to persuade the patients of that.

And just because I say it doesn't mean they believe it. I have become better through my career at so-called being a deal closer on, “We got to get you to the injectable.” But I agree with you that it takes time, it takes persuasion, it takes relationship, and it's not always day one.

Supporting PrEP Adherence in Mental Health Care Settings

So I'm glad to hear that your experience has been that it's an easier deal to close in PrEP.

Dr. Treisman: Yeah, it's been the long-actings are getting good hype and the community is accepting them and they're promoted by people in the community that ordinarily it's very hard to get people to promote. So we're pretty happy with that issue.

Dr. Fishman: Yeah.

Dr. Treisman: So supporting PrEP adherence in mental health care setting. Delivery: providing it in the context of routine visits and integration with other services.

Support: enhanced peer-based support and navigation. Telehealth-based counselling and text message intervention. I know you used—Dr. Fishman is one of the pioneers of text messaging people to try to improve their adherence and sobriety. And he's done several really cool studies with that.

Dr. Fishman: Yeah. No, that's a fun thing with medications for opioid use disorder in young adults and adolescents. We've formed partnerships with concerned significant others, usually parents and other parental caregivers, but whoever the patient selects as the person in their corner and included them on group text chats that include reminders about adherence and monitoring on progress and invitations to be involved. It seems to be a pretty effective way of giving people assistance with medication adherence.

Each adolescent or young adult is asked to designate somebody in their corner. Your mom, your dad, your boyfriend, your girlfriend. That doesn't usually work out as well, but whoever you choose who can be your treatment buddy, your treatment collaborator and can help remind you about medications and sticking with clinic visits and get good reports on you or get concerned messaging, “We missed you. You missed your dose.”

And you know, it makes intuitive sense in every other field of healthcare. It's intuitive and natural for us to swoop in when a loved one is having trouble with accessing the treatment delivery system. If granny can't take her pills, we help them. If your kid can't get to the doctor, you take them.

But no, not in mental health and addiction, right? It's in the shadows. It's shameful. It's secret. We can't talk about it. So this is kind of our attempt to normalize this and give families and other concerned significant others a clear role. Not about nagging, not about moral high ground criticism, but about helping with taking the treatment and accessing the medical care delivery system. And it's a very kind of practical kind of scope that that people seem to resonate with.

Dr. Treisman: So and then talking to them about their choices. There's the take a pill every day. There's the take pills when you think you're going to have a risk, which is sort of a hot topic whether or not you can—it's okay to wait until you're going to go on a date or wait until you're going to be sexually active and then take two pills that day, two pills the next day and a pill the next day as a PRN kind of intervention.

Dr. Fishman: Has that been studied much?

Dr. Treisman: Yeah, it has been studied quite a bit. And it's better in some populations than in others. But it's effective when people are committed to it. The problem is that it's not the morning after pill.

Dr. Fishman: Right.

Dr. Treisman: It's the morning before pill.

Dr. Fishman: And that's harder.

Dr. Treisman: It's a lot harder.

Dr. Fishman: It’s a lot harder.

Dr. Treisman: But people have shown efficacy with the two-to-one thing. And if people want to look that up, there's a bunch of papers about two-to-one. My patients have not been as interested in that. They're interested in the people who are not in the HIV clinic and not high risk, but have modest risk.

They want to be safe, particularly people who have some risk of getting infected and then infecting their spouse. Those people want to take it every day.

Dr. Fishman: Well, I like that level of motivation. I'd love to hear.

Collaboration Between Primary and Mental Health Care to Support Sustained Engagement

Dr. Fishman: Our audience is being kind of shy. So let me ask a question because I hear this question a lot from people regarding PrEP and some of the other conversations we've had about broadening psychiatric scope. Is this outside my wheelhouse as a mental health professional? I'm not an internal medicine doc.

I'm not an ID doc. And is this okay? Am I covered for this by my insurance? Am I allowed to do it by scope of practice and local regulatory authority? Am I going to get in trouble? Is it difficult and technically problematic for me? I guess that's what this slide is about. If the choice between doing it yourself or doing it by collaborative referral. But what about doing it yourself?

And is that a problem for people who are bold enough to want to do it?

Dr. Treisman: Well, I think that, you know, the idea of staying in your lane and scope of practice being limited, I think that that's all well and good if you have a very specialized thing that you do that doesn't have any impingement on other things.

But I think if you're taking care of patients who are vulnerable, our patient is a vulnerable population, vulnerable to lots of different problems. I think that you have to start to look at the person as a whole person and your role as a physician, not as a subspecialist.

So I think if you can prevent people from getting infected with HIV, which we know causes significant inflammatory stuff and depletes certain T cells that are important and changes your gut microbiome very considerably.

Dr. Fishman: And increases your risk of progression of psychiatric illness. Just as you made the point that HIV and HIV risk behaviors are a risk for psychiatric illness. They also worsen psychiatric illness if you get HIV,

if you get infected. So there's a big message of prevention there.

Dr. Treisman: Yeah. And I think that we're pushed by the ethics of being a physician to look at the whole patient as much as regulatory people want to, you know, fit you into a niche and say that's not in your niche.

I think those are artificial regulations. Physicians didn't used to do that.

Dr. Fishman: And I don't think it confers liability. Do you?

Dr. Treisman: I think that if you document in your chart why you're doing something and you say this is the risk benefit, I think your liability is very limited. These drugs are very safe and very easy to use. I think that you're not really getting into liability issues by giving people PrEP.

I was yelled at early on for treating people with HIV medicines as a psychiatrist. And the problem is the HIV doctors had too many patients to treat. And so they were dying because no one was treating them. And so I treated them.

I ran into somebody very recently who said, “Yeah, I remember when Dr. Treisman was at all the meetings, because he was prescribing more HIV medicines than and most HIV providers,” because we had a huge clinic of people who needed it. And I saved a lot of lives. Some of those patients are still my patients now.

And so I think that the scope of practice is what you decide it's going to be for patients with vulnerable comorbidities and particularly in substance abuse where you live and where our HIV clinic lives, that group of patients has huge vulnerabilities. Would you—if someone came in with syphilis, would you not treat them? Would you not attend to that and let them go on? I mean, you just – you wouldn't. You'd have to because –

Dr. Fishman: Yeah. Yeah, and that's right. And what's the line? Well, it's easy enough for my system to deliver a dose of injectable benzathine. My system doesn't hang IVs.

So for tertiary I'd have to put them in a hospital bed for – anyway, but yeah, that's right. You decide what the scope is based on what's practical and where patients can access care. And I guess a follow-up question, thinking about systems and incentivized behavior is, can people who are thinking about dipping a toe into this, can they get reimbursed? Can they get paid? Is there a way to find an incentive

gradient to get more people to do this within our health care delivery system?

Dr. Treisman: Well, I think that the billing is complicated, but I think that you can say you spent an extra so many minutes instructing people in about HIV and do that as an additional bill for psychiatric services.

And I know people do that. I think it's totally reasonable. But it probably doesn't actually pay, if you know what I mean.

Dr. Fishman: Yeah.

Dr. Treisman: It's something we do for the benefit of the patients rather than for the benefit of the pocketbook. I do think it should pay. And I think that it's insane that there isn't an incentive for primary care doctors to treat depression. A financial incentive and a financial incentive for people to see patients as a whole patient.

You should get a medal every time you get somebody sober for long term. But it's certainly not – you know, when you and I were going to psychiatry school, substance abuse wasn't a crowded field.

Dr. Fishman: No. That's right.

Dr. Treisman: And it's not.

Dr. Fishman: And by the way, the house of psychiatry has not stepped up and largely it's been other subspecialties and the new discipline of addiction medicine, which is largely come out of internal medicine, family practice and other disciplines. That's another rant for another day. But yes, your point is well taken. Psychiatry needs to step up.

Dr. Treisman: Well, when you and I came to Hopkins, there was no inpatient service where you could admit somebody in heroin withdrawal. And we were able to overcome that with our work at Hopkins, but it was – you know, we were abandoning a group of patients who really needed us.

So one approach to this besides taking responsibility is collaboration with primary care and face-to-face handoffs, specific connections so that you can communicate with a primary care doc who can help you. And then having, you know, multidisciplinary conversations with patients.

You know, with the oncologists have tumor boards and probably our patients really deserve the equivalent of a tumor board if they're really complicated, personality disorder plus a bipolar disorder plus a substance use disorder, plus HIV risk behaviors plus a paraphilia. Those people probably should have multidisciplinary interdisciplinary conversations with a whole team of people taking care of them.

Dr. Fishman: You know, that's such an interesting concept when we think about multispecialty hospital-based care, for example, as the oncology example you raise. People come together and put a lot of time and thought into case formulation for complex cases, for the average mental health professional out in the community, taking care of complex psychiatric patients day in, day out. There aren't a lot of resources for consultation and second opinion and help with multidisciplinary formulation. It's a big puzzle for our field.

Dr. Treisman: It's certainly the way things should be done, in my opinion.

Discussion: How to Support PrEP Engagement

And then you just asked the question, what's reimbursable? We have not had trouble getting people their PrEP medicines.

Dr. Fishman: In terms of coverage for the medicine.

Dr. Treisman: Yeah. In terms of getting the medicines.

Dr. Fishman: Good. And we practice in Maryland where there's fairly liberal benefits. It may not be true everywhere in the country, but in a lot of places it is.

Dr. Treisman: Right. In most places you can get people PrEP. Getting people cabotegravir injection and lenacapavir injection is going to require a little bit more effort given that those are expensive drugs and you have to justify why you would want to give people long-acting when the oral pills are cheap and generic and easy to use.

Do you think offering patients different choices of PrEP increase likelihood they will accept it due to switching to another option for patients who are currently taking PrEP, such as oral to injectable?

I do talk to them about it. If people are doing great on oral PrEP and they're not fatigued from the pills, then I – and, you know, they're usually my patients are taking several psychiatric medicines too. So it's just two more pills, or in the case of PrEP, one more pill a day. But they're taking medications. But if they're having trouble with adherence, then I always talk about injectables and other choices.

Just like I talk about injectables as you do, Marc, with antipsychotics. Getting people on long-acting injectable antipsychotics in general is good for them in terms of their psychiatric disorder, but often is resisted. I've had less – like I said, I've had less resistance to the idea of taking injectable HIV prevention drugs.

Dr. Fishman: I wonder, by the way – and this is purely speculation without any data. I wonder if it would be less difficult and less resisted by patients if it was more the standard of care and everybody thought about it routinely so that patients wouldn't think they're being singled out. “Oh, how come I have to take the shot? Everybody else takes pills,” you know. I ask everybody to take the shot. It's that kind of thing. But I don't know. I'm speculating.

Dr. Treisman: Yeah. Well, this is – you know, this is one of these things that is a long ongoing conversation about how coercive do we get to be to save money on hospitalization versus being protective of people? So if you can say we want to have outpatient commitment in Maryland, which we just got so that you can – if somebody is truly dangerous to themselves and others, you can force them to stay in treatment and take medication. But there are insurance benefits, financial benefits to keeping people on long-acting injectables because they have less hospital admissions and that saves money. And I wouldn't want it to be for the money. I want it to be for the quality of care.

Dr. Fishman: Yes.

Dr. Treisman: It's one of those things.

Dr. Fishman: Yeah. No, I think that that trumps and are being parentalistic when it's to the advantage of the patient makes sense. But not for financial incentive.

Agree. By the way, there's one other element to this question. What about providing choices? And I just want to resonate with that for a second. In general, given rough equivalence between choices. Choice, I think, helps engagement and helps self-efficacy for patients with their adherence. Obviously, if one choice is clearly better, we encourage patients to make a better choice.

But in general offering people A versus B versus C, if they're roughly equivalent, helps people get invested and research a little bit and ask some more questions and think about what's the thing that would best suit them and best motivate them to keep going. After all, in many ways, the best treatment is the treatment that a patient will do. And, you know, every parent, every mom knows that when a five-year old throws their socks off, you know, you say, “Well, you can wear the red socks or you can wear the green socks.”

Either is fine, but just not no socks. So it's that kind of thing. I think it's good to encourage choice, if you can.

Dr. Treisman: I think that you glossed over a very important psychological manipulation, which is which kind of PrEP are you going to take? Not how are you going to take PrEP?

Dr. Fishman: Yes.

Dr. Treisman: And that if you think that somebody is really at risk, I think I present it that way. If – if people have advanced COPD and they're smoking, which smoking thing are we going to try first?

Dr. Fishman: Yeah. But not are you going to cut down on smoking.

Dr. Treisman: Are we going to quit smoking now. There's a very famous –

Dr. Fishman: And that’s part of what I was talking about before is parentalism. We think that beneficence is super important and that doing what's in the interest of the patient can be congruent, usually with autonomy, if you play your cards right and you're skilled as the way you do it.

Dr. Treisman: Yes. And I think patients really actually know when you take care of them, that you care about them. And sometimes being a little paternalistic engages people in a way that you would not have expected even though they chafe under it. All life is a series of rapprochement where you go out and try something and then come back in and are safe and then go out and try something and then come back in and are safe.

And I think that knowing that they're safe with their doctor, they can talk about sex, they can talk about risk factors, they can talk about how to move forward in their life. And your advocacy for them really engages people in a long-term relationship. And many of my patients have been seeing me forever now. And they're very engaged with me.

So the follow-up schedule for mental health care when we're giving PrEP, usually the PrEP is that – we're giving way more mental health care than we are giving just PrEP. So the PrEP fits in just fine. We see people more frequently for follow-up for their mental health care than we're going to have to see them for PrEP.

A lot of people see people for PrEP twice a year. Maybe even –

Dr. Fishman: Yeah, if that's the sole thing. Sure.

Dr. Treisman: And then starting PrEP, but not managing the follow-up. And do you co-manage people or refer people? I think it's hard to refer Non-HIV infected patients for PrEP. There are primary care doctors who are happy to do it, but I think most of them are less familiar with it than you and I might be. And that many mental health people are going to be. But I think that you can find relationships where you can refer people for PrEP. There are PrEP clinics specifically and, you know, those clinics are useful as a connection if you don't want to manage people yourself.

Dr. Fishman: That's right.

Dr. Treisman: Then you can learn more about these things at our websites. There's a PrEP Made Practical: HIV Prevention and Mental Health Care Settings website. And so there's a lot of programs, both ours and others, if you're interested in PrEP and feel like you need more input.

Dr. Treisman: So Marc, are you doing this now in your program? Are you starting to do it?

Dr. Fishman: Yeah, I've certainly been doing it. As an individual practitioner, I've had more trouble moving the needle as an overall treatment center for the other medical staff that I supervise. And it's the tension that we see in all of health care.

There's so much on our plate, we're so busy. The patients are sicker and sicker and complicated, and we're running as fast as we can to stay in one place. So I ask people, why can't we assure that high-risk patients coming out of a rehab bed after a few weeks can't have PrEP be part of their standard outpatient plan of care?

And, well, I’ve got to struggle to get their psychiatric medicines right. I hear, “Well, I'm focused on getting them onto buprenorphine and I'm focused on getting them an appointment with their primary care physician.” This is one more thing that we just don't have time for. And there's – from administration, “Well, what's the financial incentive?” And I ask this before, you know, what's the financial incentive for us to move organizationally toward making that an institutional priority?

So anyway, we work towards change. I've begun more and more to talk about it in my training and supervision of the medical staff, but it's not a slam dunk quite yet.

Dr. Treisman: Yeah. I can remember in the early days of our work together, patients with schizophrenia were permitted to smoke.

Dr. Treisman: And I think that that's going to be a similar problem for this, that is people are going to say, “Can we load one more thing into the boat?” And I think that the more you load into the boat, the better the patients do and the more connected they are to you as their clinician.

Dr. Fishman: Yeah. Another analogy is we have patients who suffer from the epidemic of hepatitis C, and HCV is rife among people with psychiatric illness and substance use disorder, especially injection drug users, but not exclusively injection users. And we now have curative medicines that are relatively easy to use. But once again, I think about institutional change.

Could I make it standard practice to have every person screened for HCV and started on antivirals in a rehab bed? And I wish for that day, but I'm still figuring out, you know, how to make the financial incentives work. So we struggle in our field with these things. But I think that's an example of the kind of thing where expansion of scope, as you say, one more thing in the boat would be a good thing to have in the boat and would be better for patients.

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Dr. Treisman: So I hope this is useful to all of you. And I appreciate you joining us. And Dr. Fishman and I are, of course, very happy to be contacted if there's anything additional that you need to know.

Dr. Fishman: Sure.

Dr. Treisman: And we very much appreciate Decera for sponsoring this. It's a one of my little pet projects and one of Dr. Fishman’s little pet projects to try to actually take better care of patients with mental health issues and give them the kind of medical care and psychiatric care they need in a world where there's still new cases of HIV every year and where homeless people and chronically mentally ill people are living shorter lives rather than longer lives since 20 years ago because we provide less resources for them. And we're turning our back on a vulnerable population that we need to take care of.

So thank you guys for sponsoring this.

Dr. Fishman: Thanks for doing the work you do and your attention and interest and enthusiasm. Press on.

Dr. Treisman: And I look forward to seeing you at the next thing.