Since its release, the HIV-prevention drug Truvada has been a source of controversy.
OutSmart asks the experts—is it worth it?
by David Goldberg
How do you reconcile with a miracle drug?
Since its endorsement by the Centers for Disease Control in May, Truvada has opened up a scathing public discourse. That same week, the New York Times asked “Are We Ready for HIV’s Sexual Revolution?” on its front cover, while public figures like Larry Kramer called Truvada users “cowardly.” It seems that taking the HIV-prevention medication has become a political statement.
But Truvada’s controversy is not really based on the ethical dilemmas that come with a prescription, but from the public revelation that we just haven’t come far enough in the fight against HIV and AIDS.
“This is a tool that is equally effective as 100 percent use of condoms,” said Dr. Gordon Crofoot, an Upper Kirby-based physician who has worked with HIV cases for 34 years. Truvada—which functions as “pre-exposure prophylaxis,” or PrEP, is an antiviral drug already incorporated into the treatment regimens of 60 percent of people living with HIV. Once the medication has had time to saturate exposure-sensitive tissues in the body—namely the blood, rectum, and vagina—it can contain new HIV viruses and curtail their replication. Recent studies indicate that, if taken properly, the drug can reduce the risk of HIV transmission by 90 to 95 percent. Truvada can also be used as PEP, or post-exposure prophylaxis, which means that someone who may have risked infection can isolate and eliminate new viral cells by taking Truvada within 72 hours after exposure. However, the CDC only endorses PEP as a one-time solution for cases of a single, unusual transmission. PEP can only target one viral load in the body within a short window of time, and cannot saturate the tissue for consistent immune response. It is not as effective if taken multiple times.
Amy Leonard, Senior Director of Public Health Services at Legacy Community Health, is a vocal advocate for the drug. “We know adherence slips,” she said. “People are not perfect. That’s why it’s best to use a condom, and we know condoms are not 100 percent effective. You combine these together, and that’s very powerful.”
But here’s the thing: to work as a preventative drug, Truvada must be taken every single day. That means longer than one weekend. “You may get some blood level in a few days,” Crofoot said, “but you’re not going to get the level in [the tissues involved in sex] that would prevent the virus from getting into your body. You have to take it every day.” Studies have shown that the drug requires one week to reach appropriate tissue saturation in the vagina, and at least twenty days for the rectum—after which it must be taken daily to maintain proper levels.
Critics of Truvada see it as a way to escape sexual responsibility, and many clinicians and sexual health advocates worry that new patients will not understand what kind of an arrangement they are getting themselves into. While PrEP provides strong protection against HIV, it is no safeguard against other diseases and infections like Hepatitis C. Jaymie Mielkie, education coordinator at the Montrose Center, shares those concerns. “A lot of people are not aware of the responsibility of being on it—the testing that is involved, the commitment that is involved.”
Dr. Mark Nichols, vice president of clinical affairs at Bering Omega, said that while his clinic recommends Truvada as part of a preventative attack plan, he remains skeptical. “We don’t want people to get the wrong idea and think that maybe it is a morning-after pill, and take it after the fact.” PrEP, he argues, should not be seen as “gay birth control.” “Some people get pregnant while they’re on the birth control pill. But it’s a lot worse getting HIV than getting pregnant.” He fears that the use of Truvada instead of condoms may lead to riskier behavior, and terrible consequences. “I saw the horrors of the AIDS epidemic, Nichols said. “I’m too old-school to endorse it. I don’t think it could take the place of barriers, or of being smart with sex.”
But, ironically enough, Truvada guarantees a level of responsibility and personal awareness that far exceeds any previous form of prevention. The CDC reports that a third of gay men aren’t even tested once a year for STDs. But Gilead, the maker of Truvada, requires that all prescribers be tested at least once every three months to verify that the drug is not having adverse effects on bone density or liver function, and to ensure that users remain faithful to their daily commitment. Whether or not “Truvada whores,” as they are pejoratively called, are more promiscuous than their peers, they are obligated to deal with their decisions, their lifestyles, and their risks on a regular basis—even if they don’t feel like it.
Leonard insists that finding a field-experienced healthcare provider is essential for new users. “I just wouldn’t feel comfortable with doctors who are not accustomed to HIV regimens and medications prescribing PrEP,” she said.
James Corp, an L.A.-based 26-year-old single, is required by his provider to be tested once a month. “It gives you a sense of accountability,” Corp said. “It’s like when you are learning to manage your money; you have to budget. “If you are examining your sex life more often and looking in the mirror more, you get to be more conscious of the decisions you are making.”
PrEP also grants users an added feeling of safety as they approach encounters with strangers, or even lovers who may be HIV-positive. “For a lot of people, just engaging in sex brings up a lot of anxiety because they don’t know what their risks are,” said Keville Ware, HIV counseling program coordinator at the Montrose Center. Dr. Crofoot attests to seeing psychological benefits for his patients. “If you are negative and you are in a relationship with someone who is positive, it sort of changes what you do in the bedroom. You turn the lights off, and then on both sides there is this mind game going on, and it kind of ruins the moment. PrEP can be used as a psychological tool for [sero]discordant couples so that they relax and have fabulous sex with the one they love.”
This added layer of security affords new freedom to couples of varying statuses, and allows positive single men a chance to break away from being classified differently by their negative peers and paramours. Corp argues that using Truvada has changed his perceptions completely. “It gives me an opportunity as a sexual person to talk about HIV and not to stigmatize people who are positive. I am now more likely to sleep with someone that is HIV-positive and undetectable with a condom on, and [taking their medication], because I know my risks are minimal. That stigma of HIV is no longer there.”
Of course, PrEP is not for everyone. Patients have to undertake repeated screenings over many weeks to ensure that they are viable candidates for the drug. Without insurance, it can cost over $10,000 a year. “Most of my patients are indigent and probably couldn’t afford to take it,” Dr. Nichols said. For many obvious reasons, the medication probably won’t be able to significantly reduce transmission rates in poverty-stricken regions of our country, and in nations with rampant HIV rates in Africa. But locally, many insurance providers cover the drug and can help reduce the copay to as little as $20. What’s more, Gilead offers assistance to prescribers without insurance and, in some cases, free first-year trial coverage. Because the drug is still in a nascent phase, many clinics and LGBT centers offer free prescriptions for patients who participate in trials or studies.
Truvada is not a one-time miracle cure. While advocates and pundits discuss the ethics of sexual health, many fail to see that our community is not at a safe enough vantage point to choose the best arsenal against the disease. According to the AIDS Foundation Houston, over 27,650 Houstonians live with HIV or AIDS in Harris County alone, and one person is infected every seven hours. Transmission rates are rising, and condoms alone aren’t working. While the holocaust of the 80s and 90s may have subsided, the war against the disease is far from over, and a weapon like PrEP is necessary. “I’m seeing a lot of gay men coming into the clinic who have been infected in the past few years,” Nichols said. “Something needs to change. Whatever we are doing is not working. If this could help some people, that would be great.”
Dr. Crofoot shares Nichols’s frustration. “We can dramatically decrease the spread of HIV, and we’re not doing it. The science is there, the medicine is there, but these STDs are not going down or disappearing—and they should be.”
Until HIV can be universally prevented by vaccination, like polio before it, all forms of prevention must be promoted throughout the community—to young and old, wealthy and poor. While condoms can be shirked easily and Truvada requires too much responsibility for some, perhaps a renewed attack, with the help of clinicians, educators, and city officials—incorporating all means of preventative prophylaxis—will help decrease the spread of the virus.
Truvada is not the cure to HIV and AIDS, but it is the closest we have ever come. No form of prevention—including abstinence—is perfect. But why should such a powerful tool be so divisive? What Truvada grants its users is awareness, which is essential to changing the culture of prevention. With just hours until the next case of infection is reported in our city, there’s no time to waste on discussions of personal practices.
David Goldberg also writes about M.E.N. Inc. in this issue of OutSmart magazine.