The Big PrEP Huddle: "Sexperts" Gather to Discuss Future of HIV Prevention
Rectal microbicide. Long-lasting injectable PrEP. Implant PrEP. Even a PrEP enema.
With all the hype surrounding an easier-to-use PrEP, some very good news is being lost in the hubbub – the uptake of Truvada as PrEP has improved significantly in recent months, and that’s some good news worth swallowing.
These other forms of PrEP all are in various testing stages. Winning FDA approval could be a long way off or as early as within four or five years. So many questions need to be answered. Even if adherence concerns associated with taking a pill every day are solved with long-lasting injectables or implants, what will that mean for the possibility of creating a drug-resistant virus when a user goes off PrEP but then contracts HIV with some of the drug still left in his system?
And with many people expressing skepticism about Truvada as PrEP because they’re unsure of its long-term effects, such as its impact on kidney function and bone density, how will such fears be alleviated when even newer forms of PrEP become available? Truvada already has been around for more than 11 years (in terms of being approved to treat HIV) and its safety and efficacy is well established. Yet there are still concerns among people who don’t have HIV about taking it.
And even if additional forms of PrEP do become available, what good will they be if they aren’t getting into the hands of the people who need them?
That is the most pressing issue facing HIV prevention specialists, who are meeting in Atlanta this week to discuss HIV prevention methods during the annual National HIV Prevention Conference. Truvada as PrEP is already available, which has been proven to work not only in people who take the pill once daily as directed, but even among those who take it “on demand.” Results published last week in the New England Journal of Medicine showed that men enrolled in the IPERGAY study in France and Canada and who took PrEP “on demand” – two pills between two and 24 hours before sex, a third pill 24 hours later, and a fourth pill 24 hours after that – had HIV transmission risk reduced by more than 80 percent.
But there is a but.
“Given that participants took a median of 15 pills per month, the results of this study cannot be extrapolated to the men who have sex with men who have less frequent sexual intercourse and thus would be taking TDF-FTC on a more intermittent regimen,” the authors reported.
Getting PrEP to white gay guys with money was the easy part
Since Truvada as PrEP first was approved more than three years ago for daily use, some doctors already reported telling patients they could use it “on demand” - on party weekends and gay cruises, for example - so long as they believed they would use it properly during such party trips.
Getting Truvada into the hands of white, professional, gay and bisexual men in urban areas, and with the resources to obtain it, has been easy compared to the challenges HIV prevention specialists now face. What has proven difficult has been getting PrEP to those who may not have an employer who provides health insurance that pays for PrEP, getting it to low-income people on Medicaid (even though most Medicaid programs pay for it), and getting it to those who “fall through the cracks” (private insurance doesn’t pay or has a high co-pay and the person don’t qualify for Medicaid). Those people likely qualify for help under Gilead’s generous patient assistance program, but it can be hard to navigate.
But now progress is being made on those fronts too. Now, in the quest to get PrEP into the hands of even more people who could benefit from it, social scientists are winning research grants to find ways of getting PrEP to at-risk groups. Previous prevention methods, primarily targeting gay and bisexual men who are out and living in urban areas, don’t necessarily work for transgender women, black or Latino men who are not open about their sexuality, injection drug users, or sex workers. All of these groups are at high risk for HIV but aren’t getting PrEP at the levels needed to meet goals of ending new HIV infections. In fact, just last week HIV Equal reported that the CDC estimates that approximately a million people in the U.S. could benefit from PrEP but aren’t getting it.
Social scientists: Our best ally in advancing medical science
HIV prevention specialists in Atlanta this week are discussing the “why” behind all of this in great detail. For example, one clearly identified hurdle to PrEP uptake has been general ignorance about it among primary care providers. Because PrEP is for people who are HIV-negative, many of those who seek it – particularly outside of urban areas – approach their primary care provider (who very often these days are general nurse practitioners) and these providers sometime never even have heard of PrEP. Misconceptions about HIV medications being dangerous and toxic (a throwback to the days of AZT) remain pervasive in some parts of the country, particularly in areas that have not seen a lot of HIV infections and among healthcare providers who do no specialize in HIV.
A session at the prevention conference yesterday was called “From the Aware to the Willing: Understanding the Knowledge and Attitudes for PrEP among Clinicians and Consumers.” Other sessions included “It’s the Media Age: Dating Apps & Websites and HIV Prevention,” “Advancing HIV and Hepatitis Prevention for Drug Users,” and “Prevention Models for Traditional and Non-Traditional Providers: Guidelines and Practices.”
Today attendees will discuss “Trans Women and PreExposure Prophylaxis (PrEP): An In-Depth Discussion,” “Reaching Adolescent MSM: How Do We Find and Engage Them in Prevention?,” “License to Bare-Back: PrEP, Pleasure, and the Politics of Risk,” “Implementing PrEP in the Real World: From Theory to Practice through Community-Based Pilot Initiatives” and “Providing Practical Information for Teens, Parents, Teachers and Clinicians Regarding the Use of PrEP and nPEP for Teenagers at High Risk of HIV Infection.”
Sex workers: Is anybody there? Does anybody care?
Running in tandem this week with the official National HIV Prevention Conference sponsored by the CDC is The People’s Mobilization on the National HIV/AIDS Strategy Counter Conference. Its sponsors include ACT UP/NY, AIDS Foundation of Chicago, PWN-USA, Transgender Law Center and many other groups.
“Some major issues consist of sex workers excluded entirely from National HIV/AIDS Strategy Updated to 2020, the need of having a transparent mechanism to meaningfully involve networks of people living with HIV in the development of the strategy,” Counter Conference organizers report on their site. “Constituencies raised a number of important issues that must be critically addressed to truly achieve the bold and ambitious goals of the strategy, ranging from sexual and reproductive justice, sex worker rights, continuing issues with accurate data indicators on housing, as well as the lack of non-stigmatizing indicators for transgender and gender non-conforming people.”
The CDC holds nothing back on its website in terms of acknowledging the link between sex work and HIV. Yet few population-based studies have done on HIV risk and sex workers.
“Reaching sex workers is a critical effort for public health,” the CDC reports. “Not only are sex workers at risk for higher rates of HIV and other STIs, sex workers who are unaware of their HIV status can endanger their own health and increase their risk of transmitting HIV or STIs to others.”
Unfortunately, the chances of this occurring may be very high. “Some sex workers may know that they are living with HIV but may be reluctant to seek care or reduce their risk behaviors because of mistrust of the health care system, loss of income, drug dependency and mental health issues,” the CDC reports.
As for condom use, “Sex workers may receive more money for unprotected than protected vaginal and anal sex,” the CDC reports, adding, “In some jurisdictions in the United States, suspected sex workers who are caught with condoms in their possession can be arrested for suspicion of prostituting.”
A panel discussion at the Counter Conference today titled “Red Umbrellas and Red Ribbons – Movement Solidarity and Supporting Sex Workers Rights” will discuss “how the HIV community can support sex workers in practical ways and join with them in working together politically to eliminate ‘condoms as evidence’ policies, police harassment and other discriminatory practices that violate sex workers’ rights.”