Even those most at risk have trouble believing how far HIV prevention has come. There's now a pill that can substantially drive down the risk of contracting HIV — and it's often free of charge.
PrEP — as it's known — is the big topic for a World AIDS Day summit in Nashville on Friday. But the daily regimen hasn't become as popular as public health officials would like.
A sobering statistic from the Centers for Disease Control rocked the gay community this year — if the trend continues, one in two African-American gay men will get HIV. And the odds are worst in the South.
"HIV has a face, and I'm the face," Ajamu Coleman says. "So as a black gay man, ok, I should be worried."
Even though he doesn't have HIV and it's become much more treatable, Coleman says it's still a daily fear. But when he heard about this preventative medicine that's been approved for use since 2012 — under the brand name Truvada — he was reluctant. That's despite the drug maker Gilead covering the costs. It wasn't until he started as an outreach worker that he came around.
"If I'm going to tell people you should use PrEP or get on PrEP, I feel like I should try it myself," he says.
There are some reasons to be hesitant, such as side effects that include potential kidney problems. Patients are also told they still have to use a condom.
But the barriers are often more socially complicated, especially in the South where the social stigma around homosexuality is amplified. Taking this drug is sort of an admission that you're sleeping around.
"I've had people tell me, 'oh, I'm not really out here, I'm not having sex, I'm not really sexually active,'" Coleman says. Then he asks how many partners they've had this year, and they say 15. "Ok, you're sexually active."
The drug is also the same basic medicine used to treat HIV, which feels funny to some. And being on the medication requires HIV testing every three months, which can be nerve racking.
"I'm included. Every time I get an HIV test, I'm super nervous," says Jacob Maldonado, who conducts HIV testing and is also on PrEP.
He's part of another high-risk group — gay Latinos. He says macho culture especially gets in the way of the latest HIV prevention. But Maldonado appeals to reason.
"If we live in an age where there's a pill out there to prevent it, why not take it?"
It's not just hesitation keeping some men from taking the preventative pill. Sometimes the roadblock is finding someone to prescribe it.
Neighborhood Health's clinic near Nashville International Airport is one of just a few providers in town that regularly prescribes PrEP. The federally-funded network of clinics will begin offering the regimen at all of its sites in January.
Nurse practitioner Kim Rivers oversees roughly 185 patients but says some providers make a moral judgment.
"I imagine it's rather like when birth control first hit the market — good lord, people are going to be having sex in the streets," she says.
Rivers says her own doctor won't prescribe PrEP. Even the city's public health department hasn't started. But it's not all about morality.
"I think they're intimidated by it," Rivers says. "For so long, HIV was the purview of infectious disease, and everybody else stayed away from it."
Now that prevention has advanced beyond condoms and special lubrication, Rivers says primary care doctors will have to realize that HIV prevention should be their concern.