Issue:  Vol. 48 / No. 8 / 22 February 2018

Campos seeks funds for PrEP access


Supporters of Supervisor David Campos's plan to expand access to PrEP rallied on the steps of City Hall September 18 before heading inside for a hearing on the proposal. Photo: Liz Highleyman
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Supervisor David Campos on Tuesday, September 23, introduced legislation requesting supplemental budget funds to expand use of pre-exposure prophylaxis, or PrEP, to prevent HIV infection.

The request for $801,600 now goes to the board's budget and finance committee.

Campos proposed a PrEP resolution at last week's Board of Supervisors meeting, which was discussed, along with the budget request, at a hearing of the board's Neighborhood Services and Safety Committee on September 18. The hearing was preceded by a PrEP rally on the steps of City Hall.

"The AIDS movement started in San Francisco, and it's only fitting we begin to eradicate HIV here in the city once and for all," Campos, who is gay, said at the rally.

The resolution, co-sponsored by gay Supervisor Scott Wiener and Supervisor Eric Mar, states that the city "supports the expanded use of PrEP as an important means for ending the HIV/AIDS epidemic," and asks the health department to submit by December 1 a plan to increase the use of PrEP that addresses educational and affordability issues.

After the resolution was introduced last week, Wiener announced in a Huffington Post article that he was taking PrEP, saying he hoped to raise awareness and reduce stigma.

The supplemental budget request made Tuesday was co-sponsored by Mar and Supervisors Jane Kim and John Avalos. Wiener also spoke in favor of it.

The Food and Drug Administration approved Gilead Sciences' Truvada (tenofovir plus emtricitabine) for PrEP in July 2012. Studies have shown that when used consistently, once-daily Truvada reduces the risk of HIV infection by more than 90 percent. In May the Centers for Disease Control and Prevention recommended that people at substantial risk should consider PrEP to prevent HIV infection, and the World Health Organization also recently recommended PrEP as an option for at-risk gay men.


PrEP hearing

Last week's rally and hearing brought out nearly 100 health officials, researchers, service providers, and community members, many of whom spoke in favor of the city taking an active role in expanding access to PrEP.

"DPH fully supports PrEP as an effective HIV prevention strategy," said deputy health officer Susan Philip, director of the city's STD Prevention and Control Services Section.

In 2010 San Francisco was the first city to offer antiretroviral treatment to everyone diagnosed with HIV regardless of CD4 T-cell count, years ahead of national guidelines, Philip recalled. The city now has an opportunity to "stay ahead of the curve" by implementing a new prevention strategy.

San Francisco was one of two U.S. sites for the international iPrEx PrEP trial of gay and bisexual men and conducted one of the first PrEP demonstration projects (along with Miami and Washington, D.C.). Yet only about 800 residents are currently using PrEP, according to researcher Robert Grant of the Gladstone Institutes.

In 2013 there were 359 new HIV infections in San Francisco, according to DPH figures. Based on an informal calculation of "numbers needed to treat," Grant estimated that about 6,000 at-risk San Franciscans should be on PrEP, which could reduce annual new infections to less than 50.

The iPrEx open-label extension study found that there were no new HIV infections among men who took Truvada at least four times per week, Grant reported at the International AIDS Conference in July. However, overall effectiveness was only about 50 percent because some participants did not take it regularly.

The study also showed that taking PrEP does not lead people to engage in more risky sexual behavior. "Some expected PrEP to unleash a storm of sexuality," Grant said. But instead, "people often become more mindful of their sexual goals, more talkative with their partners, and when they take PrEP in calm moments they plan for their long-term safety."

"One of the things we do really well [in San Francisco] is follow the evidence, and sometimes we create the evidence," said HIV Prevention Planning Council member Laura Thomas. "We pride ourselves on overriding barriers to health care. This is an issue of health care justice, reproductive justice, and racial justice."


Costly but cost-effective

With Truvada priced at approximately $1,400 per month, cost is a potential barrier to wider PrEP access.

While many insurance plans cover PrEP, some make people "jump through extra hoops" such as prior authorization, David Evans of Project Inform explained at a PrEP forum last week. Some people who chose cheaper Affordable Care Act plans with high deductibles have been shocked by how much they have to pay.

Speaking at the hearing, community advocate Erik Gibb said that while he is lucky to get Truvada PrEP though his private insurance, he has an annual co-pay of $3,000.

Campos's proposed supplementary budget request for just over $800,000 would be used to hire "navigators" to help people access PrEP through existing funding mechanisms – including private insurance, Medicaid (Medi-Cal), and Gilead's patient assistance programs – and to provide co-payment assistance for people who fall through the cracks.

Contrary to some media reports, Campos's resolution does not call for free PrEP for all paid for by the city, and his plan is intended to "minimize the impact on the general fund," he said. Several speakers at the hearing stressed that funding for PrEP should not be taken from other HIV-related services.

"To those who say we can't afford it, it is not only morally the right thing to do, but financially it makes a lot of sense," Campos emphasized, as every new HIV infection prevented saves $355,000 in lifetime treatment costs.

"We have the resources to do this and we can and should do it because it works," Brian Basinger of the AIDS Housing Alliance said at the rally. "This will promote the notion that queer lives matter."


Other barriers

But cost is not the only barrier to PrEP, according to speakers at the rally and hearing.

"There's still enormous stigma, as we see every time there's a public health measure that addresses sex," Wiener said, comparing the debate over PrEP to claims that birth control or the HPV (human papillomavirus) vaccine will cause women to become promiscuous. "Stigma, shaming, and stereotyping have to end. ... We have to take a scientific and public health-based approach to making PrEP available to our community."

Though gay men have received the most attention around PrEP in the U.S., they are not the only group that stands to benefit.

Shannon Weber from the Bay Area Perinatal AIDS Center said that PrEP is "the first female-controlled method of HIV prevention" that women can use without their partners' knowledge.

Weber explained that an earlier form of PrEP – giving HIV-positive women antiretrovirals both for their own health and to prevent mother-to-child transmission – has been standard practice for many years. For the past decade, no babies born to women with HIV in San Francisco have been infected. Now, Truvada PrEP offers an option for HIV-negative women who wish to conceive a child with an HIV-positive man.

"[Condoms] will always be a central tool in the fight against HIV, yet we know that there are also many people for whom condoms simply do not work," James Loduca of the San Francisco AIDS Foundation testified. "PrEP has the potential to be a game-changer. It has a degree of forgiveness: the pill you took yesterday provides some (not optimal) protection today. The condom you used yesterday will not protect you if you don't use a condom today."

None of the more than 20 people who offered public comment at the committee hearing spoke in opposition to PrEP.

"Our society, our doctors, and our scientists have aspired to find a way to prevent transmission of HIV," said Edwin Lindo of the San Francisco Latino Democratic Club. "Well it's here today. We have the opportunity to save a generation of people who can say, San Francisco stood up for us first, and the rest of the country is going to follow."


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