In February, the Mississippi State Department of Health began offering free telehealth services across the state so residents could access PrEP, a breakthrough drug that reduces the risk of contracting HIV by 99 percent and has significantly helped slow the spread of the virus. This was good news for the state, whose capital city has the highest rate of infection in women and the fourth-highest rate overall in the United States, disproportionately affecting Black residents. Thomas Dobbs, Mississippi’s chief health officer, estimated that hundreds, if not thousands, statewide stood to benefit.

Since it began, though, the online program has been used by four people.

According to the 2019 National HIV Surveillance Data System report, released by the Centers for Disease Control and Prevention on Thursday, new HIV diagnoses are on the decline, dropping 8 percent from 2015 to 2019. In young gay and bisexual men, new diagnoses dropped 33 percent, probably because of an increase in the use of PrEP — nearly 23 percent of eligible people were taking the once-daily drug in 2019, compared with about 3 percent in 2015.

But progress in the prevention of HIV, which can lead to AIDS, has been uneven. Black and Latino Americans continue to be infected at rates much higher than White Americans — eight times and four times as high, respectively. And in Mississippi, new diagnoses have remained high year after year, between 424 and 509 each year from 2014 to 2019. The state has the sixth-highest rate of HIV in the country, and Jackson remains inundated with new cases.

Health officials and advocates say a complex mix of cultural, logistical and economic factors is preventing Mississippians from accessing PrEP — and preventing doctors from prescribing it. Dobbs puts it bluntly: “People don’t want to talk about sex in the South.”

When PrEP was introduced in 2012, the health department had a list of PrEP providers on its website. For the entire state, just two doctors were listed, said Liz Sharlot, a spokeswoman for the department.

“Over the years, we have gotten more providers, but we found that a lot of providers were uncomfortable even talking about HIV,” she said.

After a push by the department to discuss sexual history with patients, more providers have been added to the list. Still, Dobbs said many practitioners don’t know the true number of patients who need PrEP because they do not have conversations about sexual history.

In the absence of those discussions, telehealth services put patients in charge of their care.

“A lot of folks think about it but [doctors] don’t have the comfort level of the experience with it, so we want to lower that barrier,” Dobbs said. “We want to make it so someone can access PrEP through their cellphone in a place where they’re comfortable.”

The program comes after the department received a $1.6 million grant from the Ending the HIV Epidemic in the U.S. program, part of an $87.5 million effort in fiscal 2021 from the Health Resources and Services Administration. The money is part of an initiative started under the Trump administration, with a goal of decreasing the number of new HIV infections to fewer than 3,000 per year by 2030, according to the agency, focusing on rural areas such as Mississippi.

Leandro Mena, director of the Center for HIV/AIDS Research, Education and Policy at the University of Mississippi Medical Center, has changed how he approaches the concept of PrEP with patients. He no longer asks whether they’re at risk, intentionally avoiding the word because the majority of patients don’t think they are.

“I realized, what I call ‘risk’ is what a 17-, 18-year-old calls dating, someone else calls it their job, they’re going to work,” Mena said. He points to a study he conducted over three years with people ages 18 to 25. Of those who tested positive for HIV, 90 percent said they weren’t at risk in the 12 months before the positive test. Further, Mena said, women answered, “I don’t know,” when he asked how they contracted HIV.

“They have one partner, they don't know their risk,” he said.

Rob Hill, Mississippi director of the Human Rights Campaign, said it’s challenging for members of the LGBTQ community across the state to find competent medical care relating to LGBTQ health and sexual health in general.

When discussions about sexual health are had in doctor’s offices between providers and members of the LGBTQ community, judgment can often enter the conversation. If a patient feels shamed, Hill said, they’re not going to seek the care they need.

With PrEP so readily accessible via telehealth, “we should be shouting from the rooftops and the pulpits,” Hill said. But the former minister said that’s not likely to happen, noting that Mississippi classrooms teach abstinence in lieu of any other sex education.

Open Arms Clinic in Jackson has been offering free telehealth services for PrEP since 2015, and the University of Mississippi began doing so in 2017. They can provide PrEP prescriptions immediately, after a negative HIV rapid test. The health department will bill insurance if patients have it, and if not, social workers will ensure that they don’t pay any out-of-pocket expenses. Even with the cost covered, access remains a problem.

Mississippi is largely rural and, despite a recent push to install broadband across the state, many still don’t have reliable Internet access. Without it, telehealth services aren’t an option.

Although telehealth “has amazing promise,” Mena questions whether it “can leave the most vulnerable population behind.”

“Who is the population we’re trying to serve?” he asked. “You set up a telehealth program to set up people who are working poor in Mississippi. The question is: Do they have broadband? … African Americans, Latinos, people of color, who happen to have the highest rate of STIs [sexually transmitted infections] are less likely to have broadband in their house.”

Access to care isn’t limited to location, said Deja Abdul-Haqq, director of the Office of Organizational Development at My Brother’s Keeper.

“You're talking about cost, you're talking about health literacy,” Abdul-Haqq said. “When we mean access, proximity is just one of the bullet points.”

PrEP requires those taking the prescription to be tested for HIV every three months. Open Arms at the University of Mississippi Medical Center and the state health department offer alternatives for those who can’t make the drive to Jackson, with testing by mail and an option to test at a local health department. But even mail testing presents issues for some, Mena said, particularly young adults living in rural areas.

“How likely is it that they’re going to be comfortable receiving a kit at home, without anyone opening it or asking ‘What is this for?’ ” Mena said. “What are the consequences that they may suffer should people find out they are gay or bisexual, or they have sex with men?”

Mississippi advocates of PrEP repeatedly stress the value of a multifaceted approach to combating HIV. Education is key, and conversations about safe-sex practices could be lifesaving.

“We have to demystify what HIV is so we’re better equipped to educate people about what PrEP is as a solution,” Abdul-Haqq said.