In the last year and a half since the AIDS drug Truvada was approved by the Food and Drug Administration for HIV prevention use, doctors in San Francisco and other cities have noticed something surprising: there is little interest among gay men to take the pill. An analysis by Gilead Sciences, which makes Truvada, showed that based on data from more than half of retail pharmacies nationwide only 1,774 people filled prescriptions from January 2011 to March 2013, according to an article in the New York Times . While that does not include the thousands of people receiving the drug as research participants, it's still an indication that the so-called morning after pill, hailed by AIDS doctors and researchers as a way to prevent transmission of the HIV virus, has not been embraced by gay men and others. San Francisco Dr. Lisa Capaldini, who's treated gay men for many years, told the Times that PrEP has "gotten tons of attention at HIV meetings as a new tool for prevention, and I consider it an important option for the right person. And yet there's been very little interest among my patients. There's a fascinating disconnect."
What's equally interesting is that during the debate over a morning after pill that would prevent HIV (and Truvada has been found to be very effective if taken daily) many people were fearful that gay men in particular would abandon condoms and all start taking Truvada. Clearly that hasn't happened.
There are several potential explanations for gay men's ambivalence toward Truvada. First of all is the cost at $1,000 per month – although Gilead has a patient assistance program that provides the drug to those who cannot afford it. Another is the fact that in order to be effective, the pill needs to be taken every day, not every other day or only after unprotected sex. And that daily dose can result in side effects that may dissuade gay men, like kidney damage and bone density loss, which while rare, are potentially serious.
In the Times story another reason was mentioned by Dr. Kenneth Mayer, a professor of medicine at Harvard and the medical research director at Fenway Health in Boston. "We've had several decades of the recommendation to use condoms," Mayer said. "Now we're saying, 'Here's a pill that might protect you if you don't use condoms.' So it's flying in the face of community norms."
For years we've reported on "condom fatigue" among gay men, and figures from the Centers for Disease Control and Prevention back that up: the proportion of gay men who reported having unprotected anal sex in the previous year rose to 57 percent in 2011 from 48 percent in 2005, the Times noted.
There's also evidence of stigma attached to gay men by their doctors, with some reporting negative reactions from their physicians when Truvada is discussed, due to assumptions that it will increase promiscuity and diminish safe sex practices. The term "Truvada whore" is now popping up on social media sites.
In short there seems to be a need for more education – for doctors and gay men. We'd like to see the Gay and Lesbian Medical Association take on the task of providing information to physicians so that they know how to conduct a respectful, honest discussion with their patients and gay men can be comfortable with their doctors discussing available options, including Truvada. We're certain straight men aren't labeled "Viagra whores" when they're prescribed that little blue pill.
This is an opportunity for HIV/AIDS organizations in San Francisco to hold town halls this year on PrEP. Such meetings have been occurring with regularity since before Truvada was approved, but now that it's available, these forums can provide information on the potential benefits and risks associated with taking it. There is a need for more information in general since it seems that not all gay men even know about PrEP.
We're certainly not advocating that every gay man start on PrEP. That's a decision between a patient and their doctor. But it should be a collaborative decision based on facts and an honest assessment of the benefits versus the risks.