With fewer than 2,000 people using Truvada as PrEP, where is all the wailing coming from?
GETTING PrEPPed | Advocates say daily use of Truvada helps prevent an HIV-negative person from seroconverting to positive, but the key is compliance. (Illustration by Kevin Thomas/Dallas Voice)
Editor’s Note: This is the second part of a two-part series on PrEP.
Ask a group of gay men what they think of Truvada, and you’re likely to get a response that goes something like this: “I don’t like it. What is it?”
When Dallas Voice recently asked 10 gay men for their opinions on Truvada, only three said they know what it is and are aware of the controversy it ignites in the community. That controversy pits advocates against opponents, and the discussion can torch emotions like a flamethrower on a fuel depot. But why?
Truvada is an HIV medication included in the category called nucleoside reverse transcriptase inhibitors (NRTIs). It prevents HIV from altering the genetic material of healthy CD4 cells, which prevents the cells from producing new virus and decreases the amount of virus in the body.
Marketed by Gilead Sciences, Truvada was first approved by the U.S. Food and Drug Administration in 2004 as a component of therapy for people living with HIV. In 2012, the FDA approved the drug as pre-exposure prophylaxis (PrEP) to prevent HIV among those at high risk for the infection — in conjunction with condoms and other safer-sex measures.
Kirk Myers, CEO of Abounding Prosperity, was one of the Truvada advocates who testified before the FDA.
“Truvada isn’t the end-all-be-all, but people should have a choice to decide if it works,” he said. “The masses aren’t aware of PrEP and its usage.”
Two major studies suggest that PrEP with Truvada may work. In the iPrEX study of 2,499 HIV-negative men and transgender women who have high-risk sex with men, those who took Truvada had 42 percent fewer HIV infections than those who did not. There was no evidence that taking Truvada increased incidents of unsafe sex, although study patients weren’t certain if they were getting Truvada or an inactive placebo.
The Partners PrEP study enrolled 4,758 heterosexual couples in which one member was infected with HIV and one was not. That study indicated Truvada reduced the risk of HIV infection by 75 percent.
Fire up the flamethrower.
“This is where the community turns on its own,” said one man who identified himself as Dan. He says he’s in a serodiscordant relationship (where one partner is HIV-positive and the other is negative) and is one of the three men who told Dallas Voice he’s familiar with Truvada. He declined to provide his last name, saying his partner works for the city of Dallas, and he doesn’t want to create any “backlash.”
“I read how a lot of people attacked Tyler when he wrote that piece about Truvada,” Dan said. “You want to see gay men turn on each other? Mention Truvada to people who know what it is, but you better stand back. It gets ugly.”
Dan is referring to Dallas Voice contributing writer Tyler Curry, who wrote an article about Truvada titled “PrEPing for Battle.” In the Jan. 31 article, Curry presented both sides of the Truvada debate and wrote “PrEP is simply a new tool in the fight against HIV that offers an additional method of protection to condoms or abstinence.”
Sounds good, so why the gnashing of teeth when talking about Truvada?
“Have you heard the term ‘Truvada whore’?” Dan asked. “You see, to talk about Truvada as treatment means we have to talk about how we’re having sex. We have to talk about how gay men are having unprotected sex, and we don’t want to acknowledge that. We want to act superior and say we don’t do it and point fingers at those who do.”
Myers points out that many people say Truvada will give gay men a license to be promiscuous and engage in high-risk sex.
“We get that from the religious right and other opposition groups,” he said. “But the fact remains that people are entitled to know about the drug and how it can be one more tool in the tool chest.”
Myers said 305 people recently completed a two-hour training course on Truvada offered by Abounding Prosperity. The course, available over a 12-month period, was broken down into individual and group sessions.
“We found that the community was interested, and they came out of it wanting to know why they hadn’t been given the option of using the drug.”
In Dallas and Fort Worth, no AIDS agency offers Truvada as part of an HIV prevention regimen.
“It’s not a program we’re offering,” said Bret Camp, Texas Regional Director of AIDS Healthcare Foundation. “It is controversial, and there’s not an easy answer as to why it is. Both sides are very passionate.”
Camp said there are questionable interpretations to the data that has been released about Truvada as PrEP. In one study published by the National Center for Biotechnology Information, it’s suggested that taking Truvada every day reduces HIV transmission risk by 99 percent. The FDA, in its press release that Truvada had been approved for PrEP, said the drug was effective in reducing the risk of HIV infection by 42 percent.
“The efficacy rate was directly related to compliance,” Camp said. “When you’re talking about the population that would benefit the most from taking Truvada as PrEP, they’re going to be the ones who have the hardest time with compliance.”
None of the experts argue that the key to getting results from Truvada is compliance. Camp maintains, however, that it’s difficult enough to keep HIV-positive clients compliant with their medication. Training someone who is HIV-negative to take a pill daily would be difficult.
“And that’s a big problem,” Dan said. “That’s where some of the howling starts. Guys are saying that if you have a population that isn’t compliant but has stopped practicing safe sex because they think taking Truvada now and then protects them, then we’re just going to increase the HIV infection rate.”
In one of its studies, AHF reported “only 63 percent of respondents said they would be ‘Very Likely’ to remember to take the prevention pill every day.”
“And it can give someone a false sense of security,” Camp said. “People are still supposed to use condoms even when taking Truvada. Do they do it? We don’t know. People misreport sexual activity.”
Camp notes there are some people who will remember to take Truvada daily, although some experts claim the drug produces the same results when taken as little as three times a week, further muddying the statistical waters. But he paints a different picture of those clients who aren’t compliant.
“What about the person who is using illegal drugs?” he asked. “Do you think that person is going to remember to take a pill every day when he’s been on a drug-using spree for several days? Probably not.”
Dan agrees there is no question that people will stop using condoms if they’re taking Truvada, and they’ll think they’re protected when they’re not, and their partners will think they’re protected.
“And they’re not protected from other STDs,” Camp said. “If you’re having sex without a condom, Truvada is not going to protect you from other diseases. That’s a big issue.”
For Dan, Truvada as PrEP is a consideration, though.
“I’m thinking of taking Truvada because I’m in a relationship, and my partner is HIV-positive, but you should see how some of my friends react to it,” Dan said.
“There are those gay men who really think people want to take Truvada so they can just go out and have wild unprotected sex. I mentioned Truvada whores.
That’s what some people call them.”
But reports show few people are taking Truvada as PrEP. According to several accounts, only 1,744 people filled prescriptions between January 2011 and March 2013, and at about $13,000 a year, Truvada as PrEP doesn’t come cheap, although most insurance companies cover the drug.
“We haven’t had an insurance company decline Truvada coverage,” Myers said. “The assumption is when they see a prescription for Truvada, it’s for an HIV-positive client. Once the states become aware it can be used as PrEP, the companies might deny coverage.”
But Myers holds on to the idea that people should have a choice in HIV prevention.
“We’re actually one of the only organizations that offer educational programs on PrEP,” he said. “It’s absolutely recommended with condom usage, but people can’t make informed decisions if they don’t have the information. Truvada isn’t for everyone, but everyone should be able to decide if it is.”
This article appeared in the Dallas Voice print edition March 21, 2014.