Exciting developments in HIV prevention research, combined with a renewed commitment on the part of gay and bisexual men and transgender women to collective action against HIV, could make 2011 a turning point in the steady march of new infections that looms over our communities.
In November, the iPrEx study showed that, overall, 44 percent fewer infections occurred among 1,248 high-risk gay men and transgender women who took the daily HIV pill Truvada and were counseled to consistently use condoms. Among study participants who took Truvada 90 percent of the time, new infections fell by a stunning 73 percent. Participants reported that their condom use increased and number of sex partners decreased, enhancing the preventive benefits of PrEP, or pre-exposure prophylaxis. Side effects and development of drug resistance were not problems.
In July, the CAPRISA study showed that women who applied a gel containing the HIV drug Tenofovir before and after sex were 39 percent less likely to become HIV-positive. Effectiveness increased to 54 percent among those who consistently used this microbicide gel.
It is now understood that HIV-positive people effectively treated with antiretroviral medications can be up to 92 percent less likely to transmit the virus to their partners. San Francisco's model programs to encourage gay and bisexual men and transgender women to know their status and enter care and treatment early if positive are helping to slow new HIV infections.
PrEP and microbicides require additional research before they become widely available. San Francisco could become the site of a demonstration project to determine whether iPrEx's thrilling results, along with increased adherence to daily pill taking, can be achieved outside the confines of a rigorous, placebo-controlled study. In separate research, PrEP will be examined to see whether taking Truvada less frequently is as effective as daily dosing. And microbicides are being studied to assess their effectiveness in the rectum – an environment in which it is more difficult to achieve protection than in the vagina.
The U.S. Centers for Disease Control and Prevention plans to issue guidance to physicians by February describing how they can deliver PrEP to patients who want to consider it now. It may be several years, however, before public and private insurers actually pay for this costly intervention. In the meantime, it is extremely important to remember that PrEP should not be tried at home because it requires the advice and active clinical supervision of a doctor. It is critical that HIV-positive people not share their meds with HIV-negative people wanting to try PrEP, thereby threatening the health of both individuals. And there is currently no evidence suggesting that taking HIV medications less often than daily is effective in reducing one's chances of becoming infected.
Many issues have been raised about widespread use of PrEP. In addition to concerns that it may backfire by further reducing condom use, many wonder how we could even consider delivering expensive HIV medications to HIV-negative people when waiting lists for meds for HIV-positive people are growing nationally. One answer, of course, is that we cannot possibly hope to keep pace with the cost of care and treatment for HIV-positive people if we do not invest more money in slowing the rate of new infections. Spending on prevention currently represents only 4 percent of overall HIV expenditures. Additionally, unless the incoming Congress unravels health care reform, both PrEP and the cost of care and treatment of people with HIV are likely to shift from discretionary programs subject to annual budget-making whims to better guaranteed funding sources.
PrEP has been met by concerns that only the worried well will seek it out rather than people who are at highest risk for infection. Clinical guidelines and outreach for PrEP should favor people at highest risk for infection, particularly those who have genuinely tried other forms of prevention but are nevertheless vulnerable to engaging in receptive anal intercourse without condoms. Concern has also been expressed that only those who can afford PrEP will get it, further exacerbating disparities in the health of youths, low-income people, and people of color. Advocacy for payment for PrEP in those groups that most need it must be strong. At the same time, everyone who wants to remain HIV-negative deserves support to do so, and PrEP should not be denied to anyone who can benefit from it.
PrEP will be met by great moralizing among conservatives who wonder why taxpayers should be asked to pay for something that, never mind the evidence, may increase promiscuity or risk-taking. The fact is that gay men and others at risk for HIV are hardly the only people who engage in behaviors they know can result in disease, but to which they are still susceptible. Taxpayers are paying dearly for the cost of prevention, care, and treatment of heart disease, hypertension, diabetes, and smoking – far more than for HIV.
Finally, the high cost of PrEP causes many to ask an obvious and fair question: Why pay for a prevention intervention that may cost $10,000 to $20,000 per year when a condom costs 10 cents?
It is easy to see that community norms of safe sex and condom use are not as strong as they once were among gay and bisexual men. Saving PrEP as a prevention intervention only for those who truly need it, our community already has significant power to usher in the first generation of gay and bisexual men and transgender women who can live without the fear of HIV. Five things would help. We need to rededicate ourselves to using condoms when we have sex with partners whose HIV status is different from our own or whose status we are not sure of. We need to continue to build a culture in which we value protecting one another from HIV. Each of us can commit to knowing our HIV status and being re-tested regularly. And those of us who learn we are positive can enter care immediately and carefully consider early treatment. And finally, we can dedicate ourselves to participating in ongoing research on PrEP, microbicides and vaccines that offer hope of eliminating new cases of HIV once and for all.
Dana Van Gorder is the executive director of Project Inform; Matt Sharp is director of treatment and advocacy; and Alan McCord is the director of information and outreach. For more information about PrEP and HIV treatment as prevention, visit www.projectinform.org.