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After a few weeks of texting, Oliver stopped answering my messages. I took the hint and accepted that the conversation was on hold, at least for now. Oliver had first responded to an ad I placed on Craigslist with some concerns of his own. They were questions that I was excited to help him work through.

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PrEP or pre-exposure prophylaxis involves an HIV-negative person taking a pill once-a-day to lower their risk of contracting the virus. But in the 5 years after PrEP was approved by the Food and Drug Administration, the of new diagnoses in New Hampshire has remained stubbornly stable. We wanted more people in New Hampshire to get the facts and support they need to live their healthiest lives.

Four have started care but dozens more have gotten linked to other crucial services from STI and HIV testing referrals to information about payment assistance.

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For Oliver whose name has been changed here for privacyhe first wanted to know where he could get free condoms and testing for HIV and other sexually transmitted infections. From there, I assured him there were options to access PrEP confidentially if that was his concern. He grabbed those condoms, he said he found the clinic I recommended that offering free testing, and then, nothing.

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If it came back positive, Oliver could start on any of treatments able to reduce the amount of virus in his blood to undetectable levels. If the test came back negative as Oliver was expecting, there would be more good news there as well. Oliver would have variety of options to stay HIV-negative. Newer to the scene, though, PrEP and an open line to help make that a reality would also be within reach. They are less likely to know their HIV status and face special challenges in accessing preventative services like PrEP. Oliver is not yet 25 years old and thus fits comfortably in this category of heightened vulnerability.

We know that people in southern counties and men who have sex with men carry the greatest burden, but zoom in closer for a clearer view of the picture these s paint. Inthe rate of infection in Black New Hampshire residents was over 10 times that of the overall rate. The rate was over 4 times greater among those identifying as Hispanic. Inequities like these are not based on our biology but rather baked into our social fabric.

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The burdens of medical mistrust, traveling large distance to providers, and having to navigate a complicated insurance system to get covered weighs far more heavily on some us than others. The question then becomes how do we, as a community, leverage the tools we have to better care for those most affected by HIV in the Granite State? People are still getting left behind somewhere between risk and risk reduction. Those on the front lines of the epidemic must be armed with this information about the latest and greatest in HIV prevention.

This service ought to be busier, though, to have more folks calling in and spreading the word. The Granite State PrEP Line is open to all those who would benefit for connecting, from testers to harm reduction workers to public health officials to medical providers of all stripes.

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Bending the arch of the epidemic toward zero new infections requires collaboration. To do it right, as our name suggests, we need to connect.

There are no easy fixes for the reasons the Granite State HIV diagnosis rate has held so steady in recent years. We can hope and try to best to ensure the Olivers of tomorrow have an easier time making informed decisions about their own health.

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At that time, there was no agency providing services to people with HIV in Nashua, just a support group that met weekly in the local hospital basement run by Public Health nurses who saw the epidemic spreading into our community. We had entertainment from local musicians and student groups, as well as thought-provoking films and slideshows.

In Nashua, we still hold an open house with refreshments and meaningful activities to reflect on the disease and our losses as well as our progress. We also hold a candlelight vigil where all attendees are invited to read names of those we have lost from our community.

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For me, this is a moment I treasure each year, because as difficult as it is, it helps me reconnect for a brief moment with each of the lovely souls I have had the pleasure to know and care for over the past 26 years of my life. Unfortunately, for those of us who have lost loved ones to this disease, it never changes. I think of my best friend Jon daily. I know that his life, battle with AIDS, and his death shaped me and my life ificantly.

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We would love to spend this special time with you as we remember all those we have lost to this disease and honor those still fighting. You were considered at risk back then if you were a gay male especially if you were Black or Hispanic or your partners wereif you shared needles for illicit intravenous drug use, if you had a blood transfusion, were a recent immigrant from Haiti, or were born to a mom who had AIDS.

There was no medicine to treat this emerging infection and no way to tell how, or if, you were going to get sick.

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People were scared because they did not understand how the virus was passed from person to person, causing widespread stigmatization. I like to think that those of us who entered this fight back then were a little like pioneers; not quite sure where the journey would lead us, understood there could be some perils along the way, but knew there was something better just beyond the next horizon. Many of us were personally invested, having had friends who were sick or had died from AIDS. Being in the fight made us feel less helpless, when the only other choice was to passively watch our friends die far too young.

Testing for HIV antibodies became the foundation of tests, not the end. Medications were slowly FDA approved, but created another fight, for tolerability, availability and affordability. After stories of solid hard-working people being fired from their jobs began to emerge, the government acted and HIV discrimination in the workplace became protected under the Americans with Disabilities Act. Amendments were passed that made it easier for people living with HIV to meet the definition of disability. HIV infection was no longer just limited to gay men or needle sharing drug users, as women, children and heterosexual males became linked to the epidemic.

Minorities, however, continued to be over represented in the epidemic, and slowly HIV infection became more associated with what you did, rather than who you were.

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It appeared as if our educational efforts were paying off, as most people learned how to protect themselves. The first wave of people with HIV was largely made up of educated gay men; many who had strong ties to the gay community. Gay and straight friends stepped in to help.

Those friends made a lasting impression on me. They would work their full-time job, take a turn caring for a sick friend with a shift that could last from several hours to all night longthen go back to their jobs the next day and start all over again.

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Friends brought food, wiped faces, held hands, and listened. They brought the gift of comfort and made sure no one died alone. They were true heroes. Living with HIV is vastly different today. More people live with HIV than die from it.

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More people live quality lives as well as quantity. Many people either return to the workforce or never have to leave it, pursuing careers and living independently. Medications are tolerated fairly well by the majority. Medications have been affordable and accessible through private and public insurances, copay assistance from the drug companies, and by state programs using Ryan White funding. However, even with all these advances, stigma continues to be an enemy as does the increasing opioid epidemic. The newest generation of gay males has not benefited from the experience of those who lived through those early years or the educational efforts of Public Health.

Social media hook up sites give the illusion that an online profile means you know everything there is to know about another person, including their HIV status. The Millennial generation may not be the rebels like those of the generations, but their mindset of needing to learn through a variety of life experiences makes their calculated risk taking seem worthwhile no matter the consequences. The old education messages are not only ineffective to this generation but the method is as well. Social media is the preferred means of communication and doing it in real time is paramount.

As I leave direct patient care and my career of 30 plus years behind, I worry that those of us who have been doing this for many years have grown complacent and may not be up to the challenges that lie ahead.

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I told several patients in the last few years that they were living the dream. The dream of those in that first decade, who hoped medications would be discovered that not only extended life but gave back some quality. With this dream came the hope that they could go to school, stay at their jobs, marry or have happy long-term relationships, and have healthy children if they wanted.

It felt like the hard work was behind us and it would only get better.

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The reality is that though the challenges may be different now, until there is a cure, the fight is not over. There is still much work to be done, and new skills are needed to keep fighting.

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People are needed who can use social media to reach those at risk. Political voices are needed to make sure the medications we have continue to be affordable to all. Religious and spiritual leaders need to step up and make sure that all men and women are seen as worthy of respect and compassion, and are not judged according to outdated beliefs about race, gender, or sexual identity.

Without this knowledge, it will be impossible to defeat the opioid epidemic, which continues to greatly impact the HIV fight. I challenge you to do what you can to make a difference.

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