Pop a blue pill once a day and cut your HIV infection risk by up to 92 percent. That’s the amazing promise of pre-exposure prophylaxis, PrEP for short, with the HIV med Truvada.
PrEP buzz has been building for the past two years, but it’s now blowing up thanks in part to the Atlanta-based Centers for Disease Control & Prevention in May issuing the first full guidelines for how doctors should prescribe it.
But for gay and bi men and trans women, solid info on PrEP has been clouded by an often cartoonish moral debate. In 2012, a Huffington Post blogger coined the term “Truvada whores,” claiming that Truvada would spur gays to ditch condoms for reckless sex. The old-school AIDS Healthcare Foundation in California has long battled PrEP with a “No Magic Pills” campaign, and its head, Michael Weinstein, this year infamously blasted Truvada as a “party drug.”
On the other side are anti-slut-shaming activists including Adam Zeboski, whose insult-reclaiming blog “Truvada Whore” – he sells T-shirts, too – presents PrEP as an effective HIV prevention method and a tool other than condoms.
None of those extreme claims are supported by the science. The CDC calls PrEP a “powerful,” but not foolproof, HIV prevention tool. Its PrEP guidelines actually embrace some critics’ concerns, including regular HIV testing and condom-use counseling. And there’s the fact that Truvada is an expensive drug that many people may not be able to afford anyway.
“None of our protection tools are perfect or can ensure 100 percent risk reduction. There’s no one-size-fits-all,” says Craig Washington (second photo), the prevention programs manager at AID Atlanta. But, he adds, that’s why having many different HIV prevention methods is important, and PrEP is an “unprecedented” new tool.
In short, the excitement about PrEP is justified, but HIV risk is a nuanced fact that varies among individuals and communities, including in Atlanta, where young, gay black men face scary-high infection rates.
To sort out the facts and let people find out what PrEP means to them, AID Atlanta and NAESM are hosting (PrEP)aration for Life on Sunday, July 13 at the Evolution Project. Panelists will include representatives from the CDC and Truvada-maker Gilead Sciences.
Truvada is a pill that combines two different HIV-fighting drugs. The feds approved it as an HIV treatment 10 years ago. After a federal study suggested Truvada can also prevent HIV, the feds approved it as a PrEP drug in 2012. Right now, Truvada is the only PrEP drug, but new drugs likely will be developed.
According to the CDC, various high-quality studies of Truvada as a PrEP drug show it reducing HIV infection risk by 74 to 92 percent. A key study showed the risk dropping by 92 percent in gay and bi men who took the drug daily, and by 44 percent among those who took it inconsistently. It also studied at-risk straights and IV drug users, who had significant – but smaller – risk reductions.
Truvada is not a vaccine, Washington points out. It does not make people immune to HIV or give them built-in resistance to it if they stop taking the pill.
And Truvada only fights HIV. It doesn’t protect against other STDs, so condoms remain a key tool against them, activists say.
PrEP is not for everyone. Under the new CDC guidelines, it is recommended only for HIV-negative people who are at higher risk of becoming infected. That means: someone in a relationship with an HIV-positive person; gay or bi men who recently had unprotected anal sex or were diagnosed with another STD; or straights who have unprotected sex with at-risk people.
And doctors will not just hand out the pills. The guidelines call for intensive safe-sex counseling, including providing condoms and discussing their use. Regular follow-up doctor visits and HIV tests are required. In part, that is to make sure a drug-resistant strain of HIV does not develop, and that the drug is not causing long-term damage to the patient.
With a Truvada prescription carrying an estimated retail price of $13,000 a year, and all those doctor visits, affordability is a real issue.
“People with the highest need and the least resources may not have access to PrEP,” Washington says.
Some insurers may cover it, but only with higher copays and deductibles. Gilead offers some discount programs, but that doesn’t include doctor visits.
“We cannot forget that a large number of people at risk for HIV do not have any health insurance, and there are no publicly available PrEP programs in Atlanta that I am aware of,” said Dr. Colleen Kelley, an HIV transmission expert at Emory’s Center for AIDS Research. “As a community, we should be working hard to make PrEP available for all people at risk of HIV infection, regardless of their health insurance status.”
Amid such serious issues, Washington and Kelley say the popular pill versus condom debate is largely a distraction.
Kelley said no existing research shows any PrEP-related increase in risky sex, and notes that “using PrEP is not an indication to stop using condoms.”
She points out that condoms are not 100 percent effective, and that, under the CDC guidelines, PrEP is prescribed for gay and bi men who are not using condoms anyway.
“Opinions about the possibility of increasing risky sexual behavior is not a justification for withholding an effective HIV prevention intervention from a group of people,” Kelley says.
Washington ascribes anti-PrEP arguments to “internalized shame.” There are many reasons people might not use condoms –including coercion by partners or pimps – and many HIV-prevention strategies are needed because none are 100 percent effective, he says.
“We deserve that. We don’t have to earn it by being good Boy Scouts,” Washington says. “We need to get past the moralistic judgment and focus on effective means of halting this epidemic.”
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