Greg is a sexually active 24-yearold man in Lansing. HIV and other sexually transmitted infections are definitely on his radar, he says, despite saying he “always” uses a condom with casual partners.
The thin gay man admits, however, he occasionally drinks too much and “gets stupid.”
“I’m afraid of catching something. I’ve had people who were not truthful with me about their HIV status,” he says.
So for him, the idea that there might be a pill that could prevent him from getting infected with HIV in the event a condom breaks gets his attention.
There is such a pill-a-day intervention. It’s a little blue pill. No, not Viagra, it’s Truvada. Last week, the U.S. Centers for Disease Control released broad new clinical recommendations to expand use of the intervention for virtually any American at risk of infection. Faced with a steady 50,000 cases of new HIV infections a year, it’s clear that depending mostly on condoms to prevent it isn’t working.
Truvada combines two anti-HIV drugs. In 2012 after a study revealed that taking the drug daily could prevent an HIV-negative person from getting infected with the virus that causes AIDS, federal officials approved it as a prevention option, known as pre-exposure prophylaxis, or PrEP for short.
Taken daily, it has been found effective 90 percent of the time. Take less than daily, it drops to 44 percent.
The pill only works against HIV. As a result, condom use is recommended in conjunction with the drug in order to prevent infection with gonorrhea, syphilis and other sexually transmitted infections.
Some opponents of the intervention claim the new intervention will lead to gay men, in particular, to throw caution and condoms to the wind. That, opponents claim, will result in Truvada resistant HIV strains increasing in circulation and more incidents of STIs, which facilitate HIV transmission.
Studies, however, do not show an increase in syphilis incidents (the major STI used to track risk behavior in U.S. studies) nor an increase in condomless sex. Factually speaking, the estimated 90 percent efficacy of PrEP beats the efficacy of preventing seven in 10 infections that has been attributed to condoms by CDC researcher Dawn Smith.
Despite the promising science behind the intervention, uptake has been slow. Gilead, the company that makes Truvada, reported in the fall of 2013 that fewer than 3,000 prescriptions for the once-a-day prevention option had been written. Half of those prescriptions were written for women.
So why hasn’t the pill being readily adopted? Some experts say it is a lack of knowledge about the intervention. Indeed, I spent Saturday night at two local gay bars talking to visitors about PrEP. Very few even knew such a prevention option existed. And those who did generally did not have enough information to feel confident in talking on the record about it.
This was only days after the CDC issued broad new clinical guidance on the use of the drug for prevention, which made front-page news in The New York Times.
The CDC announcement had an immediate effect here on Michigan policy.
Officials at the Michigan Department of Community Health had called the science behind PrEP “promising” but had refused to endorse the intervention. On Thursday, a day after the CDC guidance was released, MDCH officials abruptly reversed course.
“PrEP is an important tool in the prevention of HIV, and the CDC guidance in support of PrEP is a major step forward. MDCH will follow the CDC guidance on PrEP and the prevention and treatment of HIV,” wrote MDCH spokeswoman Angela Minicuci in an email. “As we are still reviewing the recommendation, we will be determining how this information will be distributed.”
Jake Distel runs the Lansing Area AIDS Network. He said getting everyone on the same page about PrEP is going to be essential.
“LAAN case managers report, for example, that the agency has been advised that there are no protocols or guidances in place under which to comfortably prescribe, and provide access, to PrEP,” Distel said in an email. “This is unfortunate. We are all keenly aware of discordant couples [one person who is HIV-positive and one person who is HIV-negative] and others at continuing risk of HIV infection who would benefit from PrEP. I would hope that this new guidance from the CDC would provide the protocol and guidance needed to alter past decisions and processes.”
And despite the lack of comprehensive protocols or guidances, Ingham county residents do have access to the intervention. Dr. Peter Gulick, an infectious disease expert who runs the county’s HIV clinic, has been writing PrEP prescriptions for months.
Ingham is a particularly key location to focus resources. For years, the county has been the highest HIV prevalence rate outside Detroit — a trend that continues. Recent statistics show that one in five identified cases of HIV in Ingham County are found in people ages 13 to 24, mirroring national trends.
Of course, getting a prescription is only one barrier in PrEP access. The drug averages $12,000 or more a year. Most insurance plans and Medicaid cover PrEP. Gilead also has a co-pay assistance program as well as a patient assistance program for those without insurance.
For Greg, the intervention is likely to catch on. He became aware of it because of a Facebook group that includes many younger gay men from New York City. There, he said “everyone is on it.”
“It’s a trend,” he says. “It’s going to catch on here. Hopefully.”