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testNtreat

    PUBLIC HEALTH

    Outer Cape Prepares for Federal Ruling on HIV Prevention Meds

    Public health leaders focus on shoring up state support and private donations

    By

    PROVINCETOWN — When Jeff Schaffer learned in January that the Supreme Court would hear a case that threatened coverage of lifesaving HIV-prevention medications, he was not surprised.

    Members of the testNtreat team at OCHS in Provincetown: Alex Juchniewich, community health worker; Jeff Schaffer, founder and registered nurse; and LaKia Doncheva, community health worker and medical assistant. (Photo by Emily Schiffer)

    Schaffer, a registered nurse who founded and manages the testNtreat sexual health program at Outer Cape Health Services, said he and his colleagues are used to navigating obstacles to get their patients access to care. “There are already so many challenges,” he said.

    “Nurses in general — it’s in their DNA to find solutions and remove barriers to care,” he said. That’s why he started the program. “I saw barriers in my community and thought, how can we remove those barriers?”

    HIV-prevention medications — including a daily pill marketed as Truvada, an equivalent generic pill, and a newer injectable drug — must be covered for free by all private insurance plans sold in state and federal marketplaces and by all 40 states that have expanded their Medicaid programs under the Affordable Care Act.

    That requirement took effect in 2019, when a task force in the Dept. of Health and Human Services officially listed pre-exposure prophylaxis, or PrEP, drugs as “essential preventive medications.”

    The case the Supreme Court will decide in June, Becerra v. Braidwood, could erase that requirement.

    In 2023, a federal district court in Texas ruled in favor of a group of plaintiffs who argued that the task force’s requirements for preventive health care were unconstitutional. The plaintiffs — a group of insurance providers and “Christian” advocacy groups — objected specifically to the requirement to cover HIV prevention. They argued that the medication “facilitates homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman.”

    Schaffer is confident that, no matter what the court decides, his program will continue. “We were here in 2019,” Schaffer said — referring to the time before the task force required free coverage of PrEP. And should that coverage go away, he said, “We’ll be here to help you afterwards.”

    Looking to the State

    Leaders and health officials on the Outer Cape have been monitoring the Braidwood case for years. In 2023, state Sen. Julian Cyr called the district court ruling “an explicit attack on the life-saving HIV-prevention medication, which has dramatically reduced HIV infections in Massachusetts and across the world.”

    A Supreme Court ruling that strikes down preventive care mandates “would put us back into a place where important public health interventions would now be potentially subject to high costs for the consumer,” Robert Goldstein, commissioner of the Mass. Dept. of Public Health, told the Independent.

    Truvada, the brand-name pill that was approved for HIV prevention in 2012, costs almost $2,000 per month without insurance.

    “For something like PrEP access, that court case would be detrimental just as far as cost to the average individual,” said Dan Gates, director of the AIDS Support Group of Cape Cod. The cost barrier could weaken the effect of preventive care, Gates said, citing a 2022 Yale School of Public Health study estimating that the removal of coverage requirements could result in an additional 2,000 preventable HIV infections a year.

    Goldstein said lab tests are required for patients to begin and remain on PrEP, and those costs could run into the thousands of dollars as well.

    If the Supreme Court were to strike down the coverage requirement, “in Massachusetts, we have some inoculation,” Cyr told the Independent last week. “We’re going to watch this case closely and make sure that Massachusetts law is responsive to whatever outcome occurs.”

    After the Texas court’s ruling in 2023, Cyr worked with a group of other senators to replicate federal requirements for preventive care in the state budget. “Massachusetts has the ability to guarantee coverage in our Medicaid program as well as commercial insurance that is regulated by the state,” Cyr said. The state has less leverage over Medicare and certain retirement plans, which are governed by federal standards, he said.

    “This isn’t our first rodeo,” Gates said. “AIDS Support Group in particular was born of a time when there were not federal resources to support the need for these services. We built our system around responding to a crisis and using your own community’s resources to navigate that.”

    Gates said a lot of people don’t realize how much of what his organization does isn’t dependent on federal funding, thanks to donor support.

    Goldstein said the state spends about $1.2 million on its PrEP Drug Assistance Program, which offers full financial assistance to cover PrEP costs, including co-pays, for residents who are uninsured and earn less than five times the federal poverty rate. The PrEP DAP covered medication for 229 Massachusetts residents in the previous fiscal year, according to the DPH. “If somebody had an insurance plan that was not on the marketplace and therefore not subject to the Affordable Care Act,” Goldstein said, “the state has available resources to pay for that medication.”

    “The state is pretty invested in Provincetown having this program,” Schaffer said. Provincetown has the highest percentage of residents living with HIV in Massachusetts. As of 2022, nearly 12 percent of the town’s residents were living with HIV, according to the DPH’s latest statewide epidemiological report.

    “What Outer Cape Health Services and the AIDS Support Group have been able to do is pretty innovative in bringing a public health lens to the delivery of health care,” Goldstein said.

    Outer Cape Health Services received $228,758 in grants last year from the DPH to support the testNtreat program and an additional $176,500 for HIV case management, according to CEO Damian Archer. “There are no other direct funding sources for these programs,” he said.

    The DPH itself depends on federal grants for nearly half of its $2 billion budget, but Goldstein said that the grants come from over 150 different sources and agencies. With a diverse portfolio and a temporary restraining order on the Trump administration’s funds freeze, “we are operating with federal funds flowing and making sure that we’re doing the work that we promised we would do with those federal funds,” Goldstein said.

    TestNtreat routinely sees patients with varied insurance coverage, including people who are underinsured, uninsured, or not U.S. citizens, Schaffer said. When he started testNtreat, “I looked at it as: we do have access to testing. What about treatment and other services? People think testNtreat is so progressive, but the system is so conservative, with its roots in the eighties. Maybe we can land somewhere in the middle.”

    HEALTH CARE ACCESS

    TestNtreat Gives Top Priority to Sexual Health

    Nurse Jeff Schaffer and his team work to topple barriers to treatment

    By

    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.

    The testNtreat team (left to right): Jeff Schaffer, licensed practical nurse Meaghan Dopchev, community health worker Jaime Camacho de Sousa, and medical assistant LaKia Norwood. (Photo by Sophie Mann-Shafir)

    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.

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