This week, HIV/AIDS leaders in San Francisco unveiled their latest plan to dramatically cut HIV transmission in the next several years. We have seen these plans before, and – like the futile efforts to develop an HIV vaccine – many have not delivered on their promises. Most recently, in 2010 the Department of Public Health had set a goal of reducing new HIV infections by 50 percent by 2015. But, as we report this week, the date had to be extended two years because it took so long to implement the various programs contained in that plan. In addition to using condoms to prevent HIV, we have reported on community-embraced strategies such as serosorting (where men choose to have sex only with men of the same HIV serostatus) and seropositioning (where men determine what sexual behaviors they will engage in based on their partner's HIV status). Yet despite these practices, San Francisco still sees several hundred new infections annually – while the number of HIV cases is declining, it's not at zero, or even close to it.
This new plan, called "Getting to Zero," has one component that previous versions did not – PrEP, or pre-exposure prophylaxis. The once-a-day pill, produced by Gilead Sciences, Truvada has shown remarkable success in preventing HIV when taken as recommended. It's clear after reporting on the numerous clinical trials that PrEP is the key to lowering HIV cases, not just in San Francisco, but also around the world.
For PrEP to have a significant impact, however, two things must happen. Doctors must start prescribing it to patients who are at-risk for HIV or others who ask for it. And Gilead Sciences needs to expand its patient assistance program so that more people can afford to take it. At a cost of about $8,000 to $14,000 per year, the drug is well out of reach for those it could benefit the most: low-income people in the U.S. at risk for HIV, and impoverished people globally who live in places without a reliable medical infrastructure. (Most private insurance companies and state Medicaid programs cover Truvada.)
This week, the AIDS United Public Policy Committee, a longtime national coalition of community-based HIV/AIDS organizations, called for a scale-up of PrEP. The committee noted that while PrEP may not be appropriate for everyone, "it is clear that when taken as directed, PrEP can significantly reduce new HIV infections. The time for debate on the effectiveness of PrEP is over."
We agree.
Locally, Project Inform, a member of AIDS United, secured funding for demonstration projects to determine how to deliver this intervention most effectively, and produced educational materials to assist HIV-negative gay men with their decision to use PrEP.
"Project Inform is deeply concerned that those who could most benefit from PrEP are not yet sufficiently aware of it, and that a campaign of misinformation attempts to dissuade them from considering it," Dana Van Gorder, Project Inform's executive director, said in the AIDS United statement.
The committee pointed out that a September survey by the Kaiser Family Foundation found that 80 percent of gay and bisexual men know "only a little" or "nothing at all" about PrEP.
"People most at risk for HIV infection need to have full and accurate information to make an informed decision about PrEP, as well as support for access to and adherence to the daily medication," AIDS United noted.
Van Gorder's reference to a misinformation campaign is aimed squarely at the AIDS Healthcare Foundation. Its president, Michael Weinstein, has become a loud – and lonely – voice against PrEP, but has spun his argument carefully as more and more evidence is brought forward showing that Truvada is effective. His latest scare tactic is to run ads in gay publications, including this one, warning that HIV infection rates will dramatically increase if people go on PrEP. That's simply nonsense. PrEP has proved to be effective when taken as directed. And that's the clincher. No one would suggest PrEP would be effective otherwise. Adherence is key, as with any other medication.
AHF is also causing confusion with is its statements that rates for other sexually transmitted diseases, such as syphilis, are up. They may be in some places; in San Francisco the rates have mostly stabilized, as we reported this summer. In any event, it's an apples and oranges comparison. Truvada has not been marketed as a drug to combat other STIs. AHF has a point that condoms do protect against HIV and other STIs, but it's not accurate to conflate the two, as it's doing in its latest ad.
More to the point, AHF's practice will contrast with what it preaches. It just relocated its medical clinic in the Castro, and when we covered the opening last month, we were told by AHF officials that the nearby AHF pharmacy would fill Truvada prescriptions and that AHF would neither encourage nor discourage the use of Truvada. If AHF really believed its own ads, it would not allow PrEP prescriptions to be filled at its pharmacies.
The research is in. Truvada PrEP is effective. People at risk for HIV should talk with their doctor about taking it.