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| Truvada has been called the 'miracle' HIV pill – so why is uptake so slow? | Truvada has been called the 'miracle' HIV pill – so why is uptake so slow? |
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| Across San Francisco’s hilly streets, rainbow gay pride flags are always present, shining through the city’s persistent fog, displayed outside the city’s trademark brightly colored Victorian homes and modern apartments packed with Silicon Valley millionaires. And now this longtime west coast home to gay pride and technological innovation may soon become the country’s leader in the fight to eradicate Aids. | Across San Francisco’s hilly streets, rainbow gay pride flags are always present, shining through the city’s persistent fog, displayed outside the city’s trademark brightly colored Victorian homes and modern apartments packed with Silicon Valley millionaires. And now this longtime west coast home to gay pride and technological innovation may soon become the country’s leader in the fight to eradicate Aids. |
| This week, city supervisor David Campos unveiled a radical plan with a single goal: wipe out HIV in the city. The plans could rest on what some have described as an HIV miracle drug and others have described as a public health disaster in the making: Truvada. | This week, city supervisor David Campos unveiled a radical plan with a single goal: wipe out HIV in the city. The plans could rest on what some have described as an HIV miracle drug and others have described as a public health disaster in the making: Truvada. |
| The drug, if taken every day, has a remarkable record in preventing HIV infection, and some believe it’s as effective as condoms. Campos has introduced a proposal that would make it available to any San Franciscan – male, female or transgender – who could benefit from it. This effort is backed by fellow supervisor Scott Wiener, who on Wednesday announced that he takes Truvada. | |
| Open contributions: Are you a candidate for Truvada? Why do you – or don’t you – take it? | Open contributions: Are you a candidate for Truvada? Why do you – or don’t you – take it? |
| “The Aids movement started in San Francisco 30 years ago and it makes sense that now San Francisco is in the position to take the lead in potentially eradicating HIV infections,” Campos told the Guardian ahead of a Thursday rally in support of his proposal. | “The Aids movement started in San Francisco 30 years ago and it makes sense that now San Francisco is in the position to take the lead in potentially eradicating HIV infections,” Campos told the Guardian ahead of a Thursday rally in support of his proposal. |
| His plan is particularly striking because, while the World Health Organization and the US Centers for Disease Control and Prevention have endorsed the drug as a safe and effective in the prevention of HIV, and most insurance plans cover it, take-up has been remarkably slow. | His plan is particularly striking because, while the World Health Organization and the US Centers for Disease Control and Prevention have endorsed the drug as a safe and effective in the prevention of HIV, and most insurance plans cover it, take-up has been remarkably slow. |
| Truvada began as part of combination therapy for people with HIV. For people who are HIV negative, the FDA in 2012 approved Truvada as a preventive treatment, also known as a pre-exposure prophylaxis (Prep), a term used synonymously with Truvada. | Truvada began as part of combination therapy for people with HIV. For people who are HIV negative, the FDA in 2012 approved Truvada as a preventive treatment, also known as a pre-exposure prophylaxis (Prep), a term used synonymously with Truvada. |
| It can cost between $8,000 and $14,000 per year, though the manufacturing company Gilead offers payment plans for those who can’t get it through insurance. | It can cost between $8,000 and $14,000 per year, though the manufacturing company Gilead offers payment plans for those who can’t get it through insurance. |
| But take-up has not been wide. “It’s a boutique intervention at this point,” said Johns Hopkins’ Dr Chris Beyer, who co-chaired the WHO guidelines for Prep which were released in July. He hopes that these guidelines along with an even stronger endorsement by the CDC in July will help make the drug available in more places. | But take-up has not been wide. “It’s a boutique intervention at this point,” said Johns Hopkins’ Dr Chris Beyer, who co-chaired the WHO guidelines for Prep which were released in July. He hopes that these guidelines along with an even stronger endorsement by the CDC in July will help make the drug available in more places. |
| “If this is going to have efficacy as a public health intervention that can really reduce rates of new infection at population levels, we have to have a different model,” he said. Beyer, as well as other researchers and politicians, are trying to figure out how to get Prep prescribed to more people, especially in places where people aren’t linked closely to healthcare services. New York governor Andrew Cuomo has proposed an initiative similar to Campos’ for the state. | “If this is going to have efficacy as a public health intervention that can really reduce rates of new infection at population levels, we have to have a different model,” he said. Beyer, as well as other researchers and politicians, are trying to figure out how to get Prep prescribed to more people, especially in places where people aren’t linked closely to healthcare services. New York governor Andrew Cuomo has proposed an initiative similar to Campos’ for the state. |
| A key part of these attempts is education, but Truvada has been plagued by salacious criticism since it was introduced, and even prominent Aids activist Larry Kramer described those who take the drug as “cowardly”. The Los Angeles-based Aids Healthcare Foundation has been vehemently anti-Truvada for years and launched its latest anti-Prep campaign last month. | A key part of these attempts is education, but Truvada has been plagued by salacious criticism since it was introduced, and even prominent Aids activist Larry Kramer described those who take the drug as “cowardly”. The Los Angeles-based Aids Healthcare Foundation has been vehemently anti-Truvada for years and launched its latest anti-Prep campaign last month. |
| “Now is not the time to be throwing away the condoms,” said AHF president Michael Weinstein, who has become the most frequently quoted voice by media members looking to provide balance in articles touting the drug’s potential. | “Now is not the time to be throwing away the condoms,” said AHF president Michael Weinstein, who has become the most frequently quoted voice by media members looking to provide balance in articles touting the drug’s potential. |
| Weinstein is afraid that widespread use of the pill will cause condom use to decrease and increase risks of other STDs, which the pill does not prevent. This trend is especially concerning because while the amount of new HIV infections in the US is stable, young men who have sex with men account for the largest amount of new infections. | Weinstein is afraid that widespread use of the pill will cause condom use to decrease and increase risks of other STDs, which the pill does not prevent. This trend is especially concerning because while the amount of new HIV infections in the US is stable, young men who have sex with men account for the largest amount of new infections. |
| In any case, HIV counselors across the US point out that gay men do not always use condoms when they have sex anyway. | In any case, HIV counselors across the US point out that gay men do not always use condoms when they have sex anyway. |
| Ken Almanza, an HIV prevention specialist at AltaMed Health Services in Los Angeles, has been taking Truvada for four months. He decided to take the pill after realizing that despite his wealth of knowledge about preventing HIV, he wasn’t always following the practices he preached. | Ken Almanza, an HIV prevention specialist at AltaMed Health Services in Los Angeles, has been taking Truvada for four months. He decided to take the pill after realizing that despite his wealth of knowledge about preventing HIV, he wasn’t always following the practices he preached. |
| “My sexual habits and what I was doing didn’t necessarily always correlate with what I knew better,” Almanza said. “I know how to prevent infection, I know how you are supposed to use a condom all the time, but I know that’s not always true in the real world, for me at least.” | “My sexual habits and what I was doing didn’t necessarily always correlate with what I knew better,” Almanza said. “I know how to prevent infection, I know how you are supposed to use a condom all the time, but I know that’s not always true in the real world, for me at least.” |
| He’s also hopeful that widespread use of Prep could reduce the stigma that “bareback” or condomless sex is bad and that people who do it are therefore bad. “I just don’t want gay men to feel bad about having their sex or hide what they like because of stigmas, because of what people say,” said Almanza. | He’s also hopeful that widespread use of Prep could reduce the stigma that “bareback” or condomless sex is bad and that people who do it are therefore bad. “I just don’t want gay men to feel bad about having their sex or hide what they like because of stigmas, because of what people say,” said Almanza. |
| Aside from decreased condom use, critics are also concerned an uptick in Prep use will cause people to engage in fewer safe-sex acts like asking about HIV status or sticking with the same partner. | Aside from decreased condom use, critics are also concerned an uptick in Prep use will cause people to engage in fewer safe-sex acts like asking about HIV status or sticking with the same partner. |
| A newly released University of California San Francisco study, however, showed little evidence of “risk compensation” in a survey of 1,603 men and transgender women who were offered Prep for 72 weeks in research sites across the globe. | A newly released University of California San Francisco study, however, showed little evidence of “risk compensation” in a survey of 1,603 men and transgender women who were offered Prep for 72 weeks in research sites across the globe. |
| Gladstone Institute senior investigator Dr Robert Grant lead this study and the initial study that showed Prep could safely be used as a prevention method. | Gladstone Institute senior investigator Dr Robert Grant lead this study and the initial study that showed Prep could safely be used as a prevention method. |
| “We think that HIV prevention can be and should be like contraception,” said Grant. “In that one size does not fit at all and there is a need to be a diversity of options, so that everyone finds one method of protecting themselves that is highly attractive to them.” | “We think that HIV prevention can be and should be like contraception,” said Grant. “In that one size does not fit at all and there is a need to be a diversity of options, so that everyone finds one method of protecting themselves that is highly attractive to them.” |
| He had expected that there would be a high demand for Prep immediately after the CDC’s 2012 endorsement, but found that a lack of understanding about the drug slowed its proliferation. “Innovations disseminate slowly, which I have come to learn,” said Grant. | He had expected that there would be a high demand for Prep immediately after the CDC’s 2012 endorsement, but found that a lack of understanding about the drug slowed its proliferation. “Innovations disseminate slowly, which I have come to learn,” said Grant. |
| This slow spread comes as the amount of new HIV infections in the US continues to grow. | This slow spread comes as the amount of new HIV infections in the US continues to grow. |
| Black Americans are disproportionately represented in the amount of people living with HIV, dying from the disease and getting new infections, accounting for an estimated 44% of new HIV infections in 2010 while only representing 12% of the US population. Within that group, young black men who have sex with men account for 55% of new infections among young men who have sex with men overall. | Black Americans are disproportionately represented in the amount of people living with HIV, dying from the disease and getting new infections, accounting for an estimated 44% of new HIV infections in 2010 while only representing 12% of the US population. Within that group, young black men who have sex with men account for 55% of new infections among young men who have sex with men overall. |
| DaShawn Usher, a community education and recruitment manager at the New York Blood Center’s infectious disease prevention initiative Project Achieve, said that a lack of education about Prep is the main barrier that black men face in accessing the drug. | DaShawn Usher, a community education and recruitment manager at the New York Blood Center’s infectious disease prevention initiative Project Achieve, said that a lack of education about Prep is the main barrier that black men face in accessing the drug. |
| “It’s not just the community, it is some of the providers and the front line workers also – the people who are doing the HIV testing,” said Usher. | “It’s not just the community, it is some of the providers and the front line workers also – the people who are doing the HIV testing,” said Usher. |
| This opinion was echoed by Stephen Fallon, executive director of Latinos Salud, a Fort Lauderdale, Florida, group that works with the Latino gay community to prevent and test for HIV as well as connect people with medical care. While only making up 16% of the total US population, the Latino community accounts for 21% of all new HIV infections and 19% of people living with HIV. | This opinion was echoed by Stephen Fallon, executive director of Latinos Salud, a Fort Lauderdale, Florida, group that works with the Latino gay community to prevent and test for HIV as well as connect people with medical care. While only making up 16% of the total US population, the Latino community accounts for 21% of all new HIV infections and 19% of people living with HIV. |
| Fallon said that clinicians are often unclear on how and to whom Prep can be given to, even in Fort Lauderdale which has the highest rate of new HIV cases for metropolitan areas in the country, according to the CDC’s 2011 analysis. | Fallon said that clinicians are often unclear on how and to whom Prep can be given to, even in Fort Lauderdale which has the highest rate of new HIV cases for metropolitan areas in the country, according to the CDC’s 2011 analysis. |
| Fallon said that specific barriers for the Latino community include a financial barrier, language barriers and institutional fears stemming from their citizenship status. Some people are also afraid that prying eyes might spot Prep, which can also be used for HIV treatment, in a person’s medicine cabinet and assume that they are positive. “This already complex medical model becomes something that you’re absorbing through snippets and rumors,” said Fallon. | Fallon said that specific barriers for the Latino community include a financial barrier, language barriers and institutional fears stemming from their citizenship status. Some people are also afraid that prying eyes might spot Prep, which can also be used for HIV treatment, in a person’s medicine cabinet and assume that they are positive. “This already complex medical model becomes something that you’re absorbing through snippets and rumors,” said Fallon. |
| Another argument goes that Truvada is doomed to fail because to be its most effective, users must take one pill a day. These critics fail to acknowledge that for women, the most popular way to prevent pregnancy is the pill, which must also be taken every day. The pill has been among the most popular forms of contraception in the US since 1982. | Another argument goes that Truvada is doomed to fail because to be its most effective, users must take one pill a day. These critics fail to acknowledge that for women, the most popular way to prevent pregnancy is the pill, which must also be taken every day. The pill has been among the most popular forms of contraception in the US since 1982. |
| Dr Gail Wyatt, an associate director of UCLA’s Aids institute who has been working in the field for more than 30 years, said that adherence could be a problem for extreme high-risk populations that have little, if any, basic healthcare and would need things like therapy before they could handle taking a pill everyday. | Dr Gail Wyatt, an associate director of UCLA’s Aids institute who has been working in the field for more than 30 years, said that adherence could be a problem for extreme high-risk populations that have little, if any, basic healthcare and would need things like therapy before they could handle taking a pill everyday. |
| “Those are the folks that I think we really need to focus on if we want to stem the tide of this sea – not the people who are always at the front of the line, those would be the better educated, employed, middle-class individuals,” said Wyatt. “That’s where we usually start and then were frustrated when we can’t bring other people to the table.” | “Those are the folks that I think we really need to focus on if we want to stem the tide of this sea – not the people who are always at the front of the line, those would be the better educated, employed, middle-class individuals,” said Wyatt. “That’s where we usually start and then were frustrated when we can’t bring other people to the table.” |
| She said disparities in accessing Prep are in line with the disparities that plague the US health industry, where she said research and treatment options tend to overlook ethnic minorities and the working poor. | She said disparities in accessing Prep are in line with the disparities that plague the US health industry, where she said research and treatment options tend to overlook ethnic minorities and the working poor. |
| “I’ve been in the field for over 30 years, so I’ve seen a lot of different strategies and when there are, everybody runs to that strategy and after a while you wonder, ‘Well how long will this one last,” asked Wyatt. “Then the pendulum moves back to a more moderate approach of offering other things to people who are not adhering to this current approach so that we don’t leave people behind and we don’t just watch the disease proliferate in a certain population and not do anything.” | “I’ve been in the field for over 30 years, so I’ve seen a lot of different strategies and when there are, everybody runs to that strategy and after a while you wonder, ‘Well how long will this one last,” asked Wyatt. “Then the pendulum moves back to a more moderate approach of offering other things to people who are not adhering to this current approach so that we don’t leave people behind and we don’t just watch the disease proliferate in a certain population and not do anything.” |