PROVINCETOWN — Jeff Schaffer’s goal is to get rid of the stigma that surrounds sexual health.
“Studies have shown that when people aren’t shamed for seeking sexual health services, they feel more valued and more empowered,” says the 57-year-old registered nurse and program manager at Outer Cape Health Services. That empowerment means safer sexual behavior, he says.
When a patient tells Schaffer he’s recently gone through a breakup and thinks he’ll be acting out, Schaffer says his strategy is not to pass judgment but to “keep them safe while they’re doing that.”
Schaffer started testNtreat, a sexual health program at OCHS, in Provincetown in June 2019. The community health program focuses on sexually transmitted infections (STIs) and HIV prevention, although Schaffer’s approach to his patients is more comprehensive. “We had somebody in the community post on Facebook that they came in for a little STI treatment and they left with primary care and behavioral health,” he says.
Schaffer graduated from Cape Cod Community College with a degree in nursing in 2014. His own experience confirms the value of the services he provides.
“I have had my own years of trying to access services, my own trauma, times when I felt uncomfortable,” he says. Having borne the brunt of the stigma associated with testing and treatment firsthand led to his anti-shame approach. The stigma is dangerous, he says, because those seeking services are “really just looking for protection from situations that they don’t want to be in.”
TestNtreat at OCHS is largely funded by a grant from the State Dept. of Public Health. It operates on a fee-for-service model, wherein health-care providers are reimbursed by the state in accordance with the number and type of treatments that they provide. The grant is primarily focused on men who have sex with men, though it will also provide services for nonbinary and female-identified clients.
Since Schaffer started the program, testNtreat has expanded from a one-person operation to a team of four. He works with a licensed practical nurse, a medical assistant, and a community health worker.
TestNtreat has access to state labs that test for HIV, hepatitis C, syphilis, gonorrhea, and chlamydia infections. “We’ve also included other labs that someone might need to access PrEP, which is pre-exposure prophylaxis,” Schaffer says. PrEP is a drug administered to prevent HIV. It is most common in pill form, though the FDA approved an injectable version in December 2021. TestNtreat also offers access to PEP, which is post-exposure prophylaxis.
The main goal of the program is to increase access to testing and treatment. More frequent testing means less time that patients spend infected and contagious and thus fewer infections transmitted. “It’s a nurse-led program,” says Schaffer. “If a case is uncomplicated, then I can provide treatment as long as I’ve ruled out other things.” A case is considered “uncomplicated” when a patient does not have allergies and is not experiencing severe symptoms that suggest a separate medical problem.
If someone shows signs that “might be indicative of something more serious, then I can refer them in-house to urgent care,” says Schaffer. This is one of the benefits of a community health center that people do not always recognize, says OCHS spokesman Gerry Desautels. “We provide a cadre of services under one roof.”
Several of the challenges that Schaffer and the testNtreat team have faced are systemic. Patients “would be met with these barriers of lab costs and cost of medication,” says Schaffer, and the accumulated expense would keep them from pursuing treatment. This led Schaffer to question the treatment system that created the barriers.
Kidney health is of primary concern in patients starting PrEP, and nephrological assessments can be an impediment to the uninsured seeking same-day access. Schaffer emphasizes the distinction that “the drug is not harmful to the kidneys, it just is processed by the kidneys.” Thirty days on the medication is not long enough to create organ damage, he says, and after consulting with other treatment centers testNtreat will help patients get insurance while beginning their prescriptions. Getting access to PrEP has “certainly been made as difficult as possible,” says Schaffer. “Let’s see what happens if we make it easy.”
Schaffer has given presentations about the importance of thinking critically about the guidelines that medical professionals follow. The Centers for Disease Control and Prevention recommends that sexually active queer men be tested at least once a year for syphilis, chlamydia, and gonorrhea and every three to six months if they have multiple sexual partners. According to Schaffer, even with this range there is not universal agreement on frequency of testing.
“What does Provincetown look like between June and September?” he asks. “And what is Provincetown like between January and March? Those three months might be very different.”
When undergoing STI testing, patients are almost always asked about the number of sexual partners they’ve had in the past six months or one year. As a medical practitioner, “Are there going to be different things that you do? Or test for?” Schaffer asks. “If you see 2 or 20 or 200?” The answer is no, he says, and other sexual health professionals he’s talked to agree.
“Guidelines are guidelines, not hard, fast rules,” Schaffer says. “It’s important to say, ‘Hey, why do we ask that question?’ ”
Schaffer says that the most gratifying and painful aspects of his job are one and the same. “The best part of my job is that people come in and they love the program — they think it’s amazing,” he says. “It’s a double-edged sword,” though, because “that means they’ve had some really awful experiences.”
Schaffer says testNtreat operates differently than it would in a big city. “These are my friends and acquaintances in the community,” he says, which leads him and his colleagues to “have a bit more understanding and be a bit more invested.” And because of the small community, access to treatment can move much more swiftly. “There are times when somebody comes in in the morning, and then I’ve got three of their partners treated by the end of the afternoon,” he says.