Last year, Michael Reid began dating a guy who was HIV-positive. It was going well, but intimacy was strained.
His new boyfriend was worried about infecting Reid, and Reid wanted to know more about HIV treatment before the relationship became sexual.
Reid, of Cahokia, remembers scrolling through his Facebook feed and seeing someone talking about a preventive HIV drug. All he recalled was the word PrEP, which he later found out was an acronym for pre-exposure prophylaxis.
“I started calling doctors, and a lot of them were not familiar with it,” Reid said. Online, he came across information that connected him to Dr. Rupa Patel, who leads a PrEP program at Washington University School of Medicine.
Patel told Reid about PrEP, which includes taking Truvada, a drug that for a decade had been prescribed exclusively to treat those who are HIV-positive.
Now, it’s being recommended to prevent getting the disease, especially among those who have HIV-positive sexual partners.
After working through some apprehension, Reid, 31, decided the drug made sense for him.
“We’re still years away from ending the epidemic, but for the first time we’re seeing something that is drastically reducing the number of infections very quickly,” Patel said. “It’s a game-changer.”
Patel’s sentiment is widely shared by public health care professionals. Truvada’s use in HIV prevention has been on the rise since July 2012 when the Food and Drug Administration approved the once-a-day pill for expanded use, calling it “an important milestone in our fight against HIV.”
Truvada works by blocking an enzyme called HIV reverse transcriptase. By blocking this enzyme, it prevents HIV from making more copies of itself in the body.
Still, PrEP remains elusive for many who are at high risk for HIV. In a survey this year, the Centers for Disease Control and Prevention found that 34 percent of primary care doctors and nurses had never heard of PrEP.
What’s more, the treatment has triggered fiery debate over medical ethics, with critics — including the nation’s largest provider of HIV-AIDS care — raising concerns that PrEP could discourage condom use, leading to more risky sexual behavior.
On Thursday that group, the AIDS Healthcare Foundation, based in Los Angeles, released an ad titled “PrEP: The Revolution That Didn’t Happen.”
Despite the millions spent by Gilead Sciences, the maker of Truvada, to get community groups to promote the drug and doctors to prescribe it, “only 21,000 people are on the drug in the United States,” states the ad. “Any objective observer has to conclude that most patients don’t want to take Truvada, and doctors are not recommending it.”
The nonprofit, which defines as its mission “to rid the world of AIDS,” said in its ad the bigger problem is that the CDC “has abandoned promoting other prevention methods such as condoms.”
PUBLIC HEALTH DEBATE
The CDC offers extensive information about PrEP on its website, touting its effectiveness.
“When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92 percent,” the CDC says on its website. “PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone.”
The World Health Organization also is a strong advocate of the treatment. In 2014, it recommended PrEP for men who have sex with men. Last month, the organization issued a policy brief that greatly expands its endorsement.
“WHO has now broadened the recommendation to include all population groups at substantial risk of HIV infection,” the brief states.
But the AIDS Healthcare Foundation said priorities should be focused instead on increasing funding for HIV testing, outreach and access to health care. Those methods, the group argues, have already been shown effective in limiting transmission of the disease.
“We know that when people with HIV are treated and their virus is brought down to undetectable levels they are rendered noninfectious to others,” the group’s ad states.
But the organization does not wholeheartedly condemn the use of Truvada for HIV prevention.
“We believe that PrEP is a good solution for individuals who have multiple partners and never use condoms. However, we do not believe that it is a proven public health solution.”
That criticism is the latest in a line of challenges public health care professionals are facing in getting more patients on PrEP.
Some doctors familiar with the treatment either don’t talk about it with their patients or discourage it on moral grounds that it promotes homosexuality and promiscuity. There also is a concern that by going on the drug, condom use will decline, leading to a spike in other STDs.
Dr. David Parks, who specializes in HIV care in St. Louis, has about 200 patients on PrEP. He says there is no proof that those on Truvada will become more sexually active or more careless.
“To deny the drug is almost criminal,” Parks said. The job of a doctor, he said, is to provide the best health options for each patient.
“Those having casual sex are already having casual sex,” he said. Recommending PrEP “is not going to take a person and move them from Category A, where they are extremely selective and monogamous, and turn them into an orgy-seeking person.”
TREATMENT TO PREVENTION
Patel, who currently has 65 patients in her PrEP program, said accessibility to the treatment is not going to grow substantially until relationships change between doctor and patient.
“There are not enough providers in St. Louis asking questions around sexual health, in a nonjudgmental manner, so we can actually identify risk,” Patel said. And many patients, not open about their sexuality or sexual behavior, are not comfortable bringing it up with their doctor, she said.
“That has been identified as a problem across the country,” Patel said.
St. Louis Effort For AIDS is on the forefront of educating the public on PrEP. Last year, the agency’s workers began telling all clients who come in for STD and HIV testing about the prevention program. The St. Louis group also has been meeting with community health centers about PrEP, explaining the treatment including its cost.
The drug costs about $15,000 a year, but it’s covered by most insurers. Moreover, the drug manufacturer offers coupons to help with co-pays. In addition, St. Louis Effort for AIDS assists the uninsured with ways to pay for the drug.
The goal of community health agencies is to move from treatment to prevention, but getting young adults engaged in conversations about going on a drug proven to greatly reduce HIV infection can be a tall order, said Carolyn Guild Johnson, director of prevention services for St. Louis Effort for AIDS.
“Every kid knows the name Apple. But nobody knows Truvada,” Guild Johnson said.
Unlike so many other drugs, Truvada has not been promoted through mass advertising.
The drug’s maker, Gilead, has instead focused its resources on educating medical professionals about the drug’s newer use. And because there is no competitor, advertising is not a priority, activists point out.
But there are more grass-roots efforts under way to reach at-risk populations. For example, on Grindr, a popular gay dating app, HIV-AIDS researchers seek participants for PrEP clinical trials. And more studies are coming out boosting the effectiveness of PrEP.
Still, thanks largely to social media, PrEP is saddled with the “party drug” tag. Those who are on the treatment have been called “Truvada whores,” implying they are taking a drug only so they can continue to have risky sex.
Reid, who has been taking Truvada since September 2014, has no regrets. He has had none of the side effects that can come with the drug, including fatigue, headaches, loss of appetite and diarrhea. He is no longer with his boyfriend but plans to stay on the drug as he starts dating again.
“I say that I’m protecting myself internally (with Truvada) and externally with condoms,” Reid said. “I have seven or eight friends I grew up with, they are all positive.”
Still, when he talks with his friends who are HIV-negative, they are skeptical.
“I try to get my friends on it, but they don’t really believe in it. The think it’s a gimmick. They say it will encourage people to have more sexual partners,” Reid said.
Treatment of HIV has advanced greatly in the past decade, but controlling infection continues to be a problem. Each year, more than 40,000 people in the U.S. are diagnosed with HIV, according to the CDC. More than 1.2 million Americans are living with HIV in the U.S. today, including about 13 percent who don’t realize it, the agency said in a report earlier this year.
Expanding the reach of PrEP will significantly reduce new infections, Patel said.
“It’s the most effective tool in the prevention toolbox,” she said. “It’s the closest we’ve come to keep the negatives negative.”