by Race Bannon and Luke Adams
Originally pubished on ebar
Three years ago, we wrote an op-ed piece, “Brave new world: Test, treat, and PrEP,” and we refer you back to it (http://www.ebar.com/columns/column.php?sec=guest_op&article=347). It began a big conversation. Both of us are community organizers who spend a lot of time talking with the target populations of the “Getting to Zero” effort at HIV prevention in San Francisco, so we wrote for this paper to address some reckless misinformation in the AIDS Healthcare Foundation’s ad campaigns against Truvada for PrEP.
In those three years, the FDA has approved daily Truvada for pre-exposure prevention against HIV infection for all sexually active people who have a risk of exposure. The World Health Organization has endorsed its use and advocated for access in developing countries. The Centers for Disease Control and Prevention has offered strong endorsement. The White House Office of National AIDS Policy has included PrEP as part of the strategy to get to an AIDS-free generation. The British National Health Service, Health Canada, the Therapeutic Goods Administration of Australia’s national health insurance program, and the European Medicines Agency are now moving toward the approval and adoption of Truvada for PrEP.
Healthy San Francisco first covered Truvada for PrEP. With the rollout of the Affordable Care Act, Medi-Cal became the first state Medicaid program to cover it (Adams helped advocate directly for that) and to simplify the process. New York, Washington, and other states have followed. Most private insurers are covering it, to varying degrees. One of the pieces of advocacy we have to do about this preventive measure is to require that insurers cover this medication as a preventive with little or no co-payment. San Francisco Supervisor David Campos was the first California public official to propose finding ways to secure access and affordability for PrEP to all San Franciscans who need it. We hope that other cities and states will follow suit, and that a global pricing scheme can be adopted to pay Gilead a negotiated price for Truvada.
ACT UP, while battling Gilead Sciences’ high pricing for Sovaldi and other medications, has strongly endorsed Gilead’s Truvada for PrEP. The San Francisco AIDS Foundation, Gay Men’s Health Crisis in New York, the AIDS Foundation of Chicago, Project Inform, and every significant AIDS research or service organization in America has endorsed adding PrEP to the arsenal of prevention tools – except one. The lone organizational enemy of enhanced HIV prevention remains the controversial multinational conglomerate, AIDS Healthcare Foundation. AHF often points to certain studies to back up its deceptive myths, then cherry-picks the data cited, misrepresenting the consensus of the various studies. AHF has continued publishing ads with deceptive myths in community papers, offering deceptive media commentary to reporters, and fomenting deception from an army of social media conspiracy theorists to attack this method of prevention. We write this to dispel the seven big deceptive myths.
“There are still too many questions about Truvada’s overall effectiveness.” No, not among any reputable scientific researchers who conducted or have reviewed the studies. Truvada has been proved to be safe and effective for prevention when taken as prescribed. In demonstration projects, those who adhered to taking the medication at least four times a week had zero HIV infections (Londovitz, 2014).
“Truvada for PrEP will breed a resistant supervirus, and will infect people on PrEP.” No, since Truvada has already been in use as one of the components of treating people already infected with HIV, there has long been a virus that has potential resistance to one of the components of the medication. None of the studies on Truvada for PrEP have shown that potentially resistant viruses can break through the mechanism Truvada uses for prevention. No one, in any of the studies, who began the study uninfected and who adhered to the medication, has become infected with HIV. In fact, those who adhered to daily Truvada for PrEP had a 99 percent protection rate (Grant, et al., 2010; CROI, 2012).
“Truvada for PrEP is dangerous for your kidneys/liver/etc.” No, the PrEP studies about Truvada have shown no liver or kidney toxicities, and very minor, if any, side effects (Grant, et al., 2010). There have been some reported minor toxicities experienced by HIV-positive people who are taking Truvada to treat infection – about 3 percent have shown creatinine clearance or other kidney problems, and there was no more incidence of liver irritation – 8 percent – than with other antiretroviral medicine combinations (Gallant, et al, 2006).
“Only wealthy barebackers in big cities will be able to afford Truvada for PrEP.” No, most insurance is covering PrEP to a greater or lesser degree. Minneapolis and Baton Rouge were early adopters. We are working to make that coverage and cost more universal. Studies have shown that participants actually increased, rather than decreased, their use of condoms in certain high-risk activities (Grant, et al. 2010; Cohen, et al., 2014).
“Condoms are more effective than PrEP.” No, when used as directed, Truvada for PrEP is more than 20 percent more effective at protection against HIV than the standard usage of condoms (Smith, 2013).
“Condoms are the only way to prevent other sexually transmitted infections.” No, there are a variety of tools that can help with that. Long-standing evidence from the CDC’s Morbidity and Mortality Weekly Report shows that users of chronic large amounts of alcohol (more than five dinks at a session, more than three times per week), and users of hyper-stimulants (coke, crack, amphetamines, molly, N-bomb) are statistically more likely not to regularly test, not to get proper treatment, to have infections, and to transmit or contract HIV, so reducing exposure to that demographic can help. Among the most successful tools is for sexually active people to get tested for STIs every three to six months. Those who are on Truvada for PrEP can simply add these to the other quarterly tests they need to do. Finding and treating infections rapidly reduces the pool of pathogens in our social networks. With syphilis, any known exposure should be preemptively treated because it can take 12 weeks for syphilis to show positive on a test, and epi-treatment cuts off the risk of spreading more infections in that time. Another tool – and here’s a novel idea – is to actually have open discussions with partners about testing and treatment practices, viral load, medications, risk strategies, and what you want out of sex. Vaccines are available for hepatitis A and B, HPV, menningicoccus, and the flu. Suppressive daily treatment is available for herpes. In anonymous situations where patients feel their risk level may be higher, we have seen clients employ condoms for protection in addition to other risk reduction strategies, even when their condom use otherwise is low (Beehan, et al., tbp 2015).
“People who choose PrEP as a prevention tool for themselves will not adhere to the medication.” No, people who choose Truvada for PrEP already have an incentive, not to merely participate in a study, but to address their own personal health, and PrEP puts the power of prevention into their own hands. Truvada is only the first medication to be FDA approved in a pipeline of several to come – from more pills to adjunct gels to monthly or quarterly shots. Choices will get easier over time, not harder. We need to work on expanding access, and Campos’s leadership here has been invaluable. We also need to focus on the many psychosocial factors that impact adherence and pay for the cognitive-behavioral therapy and other behavioral health counseling that has been proven – with more than a monochromatic six-session approach – to solidify people’s lives and thus, their adherence (Psaros, et al, 2014).
Here is the truth: 1) PrEP is about responsibility: it puts power into the hands of HIV-negative people to protect themselves and their partners; 2) PrEP is about purity: when used as directed, it is 99 percent effective at preventing infection with HIV; 3) PrEP is about caring and nurturing: it reduces risk and harm and helps people optimize their health; 4) PrEP is about solidarity: it takes away the divide between poz and neg and helps us all look out for each other.
When the AIDS pandemic hit, if you had asked many people on the street if they would take a pill that could prevent HIV infection, they would have jumped at the chance. PrEP is an important new tool in the arsenal to combat HIV. In your personal decisions about it, please do not let shame peddlers and prevention denialists – like the HIV denialists before them – derail your health.
Race Bannon and Luke Adams are longtime community activists. Bannon writes at http://www.Bannon.com and is also the Bay Area Reporter’s leather columnist. Adams (@DaddyLukeSF) is a drug counselor, minister, and marriage and family therapist intern.