PUBLIC HEALTH

Pill to prevent HIV faces critics, stigma

Truvada advocates say treatment can end AIDS epidemic in U.S.

By Jeremy Redmon jredmon@ajc.com

Ben Nicoara pops an oval-shaped blue pill in his mouth as soon as he wakes up every day. Single and gay, the Atlanta resident is taking the drug to ward off HIV, the virus that causes AIDS.

Studies show the government-approved treatment — called Pre-Exposure Prophylaxis, or PrEP for short — is extraordinarily effective when taken correctly. So Nicoara and other advocates are promoting it as a way to help end the HIV epidemic still raging in Georgia and across the South. But only a small fraction of those who are good candidates for the drug are

taking it, according to Centers for Disease Control and Prevention estimates.

About 1.2 million people — uninfected gay men, people who are in heterosexual relationships with HIV-positive people, and others — could use PrEP, which is marketed as Truvada. Yet, less than 22,000 were taking it as of last year, according to one estimate.

A possible reason for the wide gap: the CDC didn’t issue guidelines endorsing the treatment until last year, so people are still learning about it. But there is also a stigma attached to it. Branding those who take it as “Truvada Whores,” critics say it could encourage promiscuity and unsafe sex and contribute to the spread of sexually transmitted diseases. The critics, which include people dedicated to fighting the spread of HIV, also highlight the possibility of human error — that people might not take it consistently as required and put themselves at risk of contracting the virus.

This contentious debate is playing out as the nation is still struggling to stop the spread of HIV. Each year, about 50,000 new cases are identified nationwide, and more than 658,000 people have already died from AIDS. The epidemic is particularly strong in the South. In 2013, the most recent year for which statistics were available, the South had a rate of 20.5 HIV infections per 100,000 residents, higher than the Northeast, West and Midwest. That same year, Georgia ranked second among the 50 states in its rate of new HIV diagnoses at 36.7 with an estimated 3,011 new cases, behind Maryland, which had a 43.7 rate.

Nicoara has been taking PrEP for more than a year with no serious side effects. He gets his PrEP from Pride Medical, an Atlanta clinic and pharmacy. He returns there every three months to get tested for HIV and to ensure the drug is not harming his organs. Nicoara said he has convinced friends to start taking the drug.

“Even if I have to deal with the nonbelievers and the name-callers, it’s worth it to me because I know friends who have become HIV-positive in the last few years and they all tell me, ‘I wish I had heard about PrEP before this happened,’” said Nicoara, 27, who works at a local transportation research firm.

Critics point out that, unlike condoms, PrEP does not prevent people from getting syphilis and other sexually transmitted diseases.

“My biggest concern overall is what I consider to be an attack on the condom culture that has been built up over the last 30-plus years,” said Michael Weinstein, president of AIDS Healthcare Foundation, a Los Angeles-based nonprofit that bills itself as the largest provider of HIV/AIDS medical care in the U.S. “If a person is sexually active and never uses condoms, then they are a good candidate for this. We are not against PrEP. We are against (using) it on a mass basis as a public health strategy.”

PrEP is a combination of tenofovir and emtricitabine, medication that has been used with other drugs for years to treat people with HIV. When taken consistently, PrEP can reduce the risk of HIV infection for people who are at high risk by up to 92 percent, according to the CDC.

The U.S. Food and Drug Administration approved the treatment in 2012. Two years later, the CDC issued guidelines recommending it for those at high risk of HIV. A report published in Current Opinion in HIV and AIDS this year estimated that as many as 21,825 people have received PrEP. That estimate is based on a national survey of 39 percent of all U.S. retail pharmacies that dispense PrEP. The survey showed that 8,512 people started taking the drug between January 2012 and March of this year, according to Truvada’s California-based manufacturer, Gilead Sciences.

A study published in the Clinical Infections Diseases journal in September found no HIV infections over more than a 2½-year period among 657 San Francisco patients who started PrEP. The study identified some areas of concern: The researchers at Kaiser Permanente San Francisco Medical Center documented 344 diagnoses of sexually transmitted diseases among the patients during follow-up visits. And of the 143 who answered a survey, 41 percent said they started using condoms less.

Another complicating factor: The drug is not cheap. It costs about $15,000 for a year’s supply, according to Gilead. But most insurance programs cover PrEP, according to the CDC. Plus, Gilead has programs that assist people who don’t have insurance or who have insurance co-pay expenses.

Some states are subsidizing ways to expand access to the drug, saying the cost of prevention is cheaper than treating HIV. New York, for example, is spending $3 million with the goal of helping make the drug available to 1,000 people at high risk of contracting the virus. Since June of last year, the Empire State has tracked a 400 percent increase in the number of Medicaid recipients using PrEP. The state of Washington, meanwhile, is spending $2 million a year on a program to help people get the drug. Since April of last year, 700 people have enrolled.

Georgia’s Public Health Department has endorsed the federal guidelines for using PrEP and is getting the word out about the drug, calling it a “powerful new prevention tool” that “has the potential to alter the course of the U.S. epidemic.” But the Peach State is not spending taxpayer money to expand access to the drug, citing budget constraints.

“We can’t just rely on one modality and think that we are going to drastically affect the rates of HIV anywhere in the country,” Dr. Gregory Felzien of the state Public Health Department said. “So we have to consider PrEP, we have to consider condom use and we also have to strongly consider getting that partner involved that is HIV-positive because of treatment as prevention.”

Fulton County Health and Wellness Department officials recently started a pilot assistance program to make the drug available. Using existing funds within their budget and operating out of their clinic across from Grady Memorial Hospital, they have prescribed the drug to four people since starting the program in September. There are plans to expand.

Nicoara said he was initially skeptical about the drug and its side effects, which are mild and can include an upset stomach and a loss of appetite. But a former boyfriend convinced him to start taking it. Now he calls it “revolutionary,” particularly for his state of mind.

“It has been 100 percent effective so far,” he said. “It kind of has been life-changing. It’s revolutionary to not have to fear HIV. And I have only been out and sexually active for about five years. I know a lot of people who have been out and gay and have been having sex for a lot longer and they have lived their entire lives fearing HIV.”

“If you could get every HIV-negative person who is what they call ‘high-risk’ to be on PrEP and get every person who has HIV to be on the right medications to treat it, HIV will not transmit,” he continued. “You could essentially eradicate it within a lifetime. I don’t understand why we are not currently backing it more than we are now.”