Is a Microbicide the Game-Changer Gay Men Need?
June 23, 2014
When it comes to cost, condoms are of course the big winner. Not only are they cheap, they're often free, and if not are easily available over the counter. Truvada is the loser here, costing thousands of dollars a year, although its manufacturer is providing the drug free to people in the U.S. who do not have it covered by insurance or Medicaid.
Fortunately, in 2006 Gilead assigned a royalty-free license for tenofovir gel to CONRAD and the International Partnership for Microbicides. IPM has made the following statement about access:
IPM is laying the groundwork to ensure that microbicides, once developed, can quickly get into the hands of women in developing countries. New drugs have historically been designed and developed for industrialized markets, and introduced into developing countries only several years later, if at all. IPM is committed to changing this paradigm by designing microbicides specifically for women in developing countries and making them available in those countries quickly as possible.
Although we won't know until the first RM is approved, there's good reason to hope that such a product will be far closer in cost to condoms than to Truvada.
Unfortunately, it's unlikely that any RM will be as easy to obtain as condoms. The FDA will most likely require that an RM like the one being tested in MTN-017 be available by prescription only, to ensure that people using it have tested HIV negative. That's an extra, but not insurmountable, hurdle in the U.S. If the Affordable Care Act increases the number of people who have health insurance it may become much smaller. Still, it will not be as simple as picking up a tube of KY jelly at the drugstore. In other countries, groups like IPM will be working to make access as widespread as possible. And we need to keep searching for an RM that does not contain any HIV meds, so that people with HIV who have receptive anal sex can use it to protect their partners. That's not recommended for RMs that contain HIV meds.
The first RM will also have to be marketed effectively. According to Jim Pickett, "I think when we do have an RM, it will be best to market it first and foremost as HIV prevention. It should be marketed as a sexy, fun lube that happens to offer protection. It absolutely should not be called a microbicide -- we need to create desire and have people want to use the product because it is pleasurable. That word doesn't conjure desire -- so it will need to go."
Harriet Langanke, director of the German Sexuality and Health Foundation, adds, "To encourage microbicide adherence among these populations, first, the microbicide must be shown to work and the protection must be effective. Availability is a significant issue, as these products must be easily at hand, at least as easily available as the male condoms, and when it comes to marketing, the product packaging itself has to either be very discreet or evoke a positive image."
Since RMs may never be as effective as using a condom every single time you have sex, one barrier to its use could be the stigma that we are currently facing with Truvada for HIV prevention. Many people, even in the gay community, can't understand how people can put themselves at risk for HIV when such a cheap, effective tool as the condom is readily available. Gay men can have a hard time admitting to their doctors that they're being unsafe, and that can be even harder to admit to peers. Carrying an RM with you for casual sex could carry the same stigma that condoms hold for some now. "If you don't have HIV, why do you have this kind of lube? Do you think that I do?" We've had to fight these battles for men using PrEP, and we need to find ways to avoid the same ones being waged when it comes to RMs.
Rectal microbicides, like condoms and PrEP, are not going to be the ultimate answer to stopping HIV. Even the first FDA-approved HIV vaccine will probably not be 100% effective. But, if proven safe and effective, and when used in combination with other methods, it is hoped that RMs will soon make a significant difference in turning around the stubbornly high infection rates we live with now. The important thing is to start asking the questions about them now, so that when the first one does emerge, we're ready to use it in to maximum effect.
Mark Milano is the Editor of Achieve.
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