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Steve Gibson on PrEP: Your Questions Answered

December 16, 2010

A groundbreaking new study shows that antiretroviral drugs (ARVs), when taken correctly and offered along with condoms and counseling, could help to prevent HIV infection. Results show that taking the drug Truvada was associated with a 43.8% reduction in HIV infections. The study involved about 2,500 sexually active gay men and transgenders from cities around the world, including San Francisco.

The method is known as PrEP (pre-exposure prohylaxis). It's an experimental approach that involves taking antiretroviral drugs before exposure to the virus.

In the wake of the PrEP study we sat down with Steve Gibson, Director of Magnet, to understand what this study means for San Francisco.

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Do the results mean I can just take a pill and I will be protected from HIV?

No. This is the first in a series of trials to determine if taking antiretroviral drugs (ARVs) orally, a pill a day, could be used to prevent HIV transmission. You must also understand, the drugs were administered as part of a comprehensive package of prevention, including counseling, condom promotion, and screening and treatment for sexually transmitted infections (STIs). So far, there is no evidence of how the pill would work without the comprehensive prevention package.

Would this mean in the future, men could stop wearing condoms for anal sex?

No. No prevention method is 100% effective. Much more research is needed -- and happily is underway -- before we can understand just how effective and practical PrEP might be in preventing HIV. But for now, this is the important message: know your current HIV status and that of your partner(s).

Condoms are the best way to prevent getting or transmitting HIV during anal sex. We also know that using condoms all the time isn't realistic or even desirable for some guys, and that there are harm reduction strategies like sero-sorting and sero-positioning that may reduce likelihood of transmission. In fact, HIV positive and negative men in San Francisco have made great strides to reduce the likelihood of transmitting or acquiring HIV by adopting some of these strategies. The hope is that someday, PrEP may be one more tool to help further reduce HIV transmission.

Will this pill protect me from other sexually transmitted infections beyond HIV?

Excellent question. No. In fact, the research shows antiretroviral drugs only have the potential to protect someone from HIV. That leaves many other STIs, like syphilis, gonorrhea, and Chlamydia, that you could still contract in your throat and butt as well as your penis.

So if people should still be using condoms for anal sex, then why do we even need a pill?

Because there remains an urgent need for a range of safe and effective prevention strategies. Approximately 2.7 million people are infected annually around the world, including 56,000 in the United States and approximately 800 to 1000 in San Francisco. Although behavior change programs have contributed to dramatic reductions in these rates, far too many people are getting infected with HIV each year, including right here in San Francisco.

We hear the phrase "adherence matters" with regard to PrEP. What exactly does that mean?

It means PrEP worked best when the study participants took all the pills they were supposed to take exactly as they were supposed to take them. So if this is eventually approved for use, we've learned that it's very important that people adhere to the regimen. This is not something that can be taken casually.

Only a small portion of study participants were successful in taking the medication daily, exactly as they were supposed to. There are several reasons for this. First, taking a daily medication is a challenge for anyone. Life happens, and people miss doses for all sorts of reasons. This is particularly problematic for HIV medications, which require strict adherence to be effective in fighting HIV.

Second, a number of people in the study experienced nausea and headaches during the first month of the trial. This is just one of the "real world" complications we have to consider as we look at PrEP and how effective it could be.

Let's talk about cost. This remains a big issue, right?

Yes. These drugs can cost more than $14,000 per year for daily doses. We are concerned that only people who can afford the medications, or people with private health care, will have access to PrEP. But advocates are focusing on drug pricing and coverage to ensure equitable access, should PrEP prove to be as effective as the recent study suggests it might be.

For now, our priority should remain providing access to HIV medication to people who are HIV positive, correct?

Absolutely. We believe, along with many in San Francisco, that anyone with HIV should be able to access proper care and treatment. We still have work to do on this front. There are still people living with HIV in San Francisco who have other more pressing life matters such as mental health, substance use, or who are homeless, that make it difficult to sustain HIV care. Addressing the health disparities among people living with HIV and AIDS in San Francisco remains our top priority.

As we've said, the use of these medications as prevention is still in the very early stages of research. But here's what we know for sure: they improve the lives of people already living with HIV. So we strongly feel that ARVs must be accessible first and foremost to all HIV positive people who need them.

So what's the big lesson from this study?

This study really underscores the need for people to know their HIV status so that appropriate prevention, treatment, and care services are made available to them. It's important to remember that 1 in 5 people nationwide who are HIV positive do not know their status.

Beyond that, this study holds promise. This may be the most significant advance in HIV health and prevention for gay men since the mid-90s with the release of more effective ARVs, giving real hope that we could someday break the back of the epidemic. It's of course tempered and qualified hope, but it is hope nonetheless, and that's significant since we haven't had that kind of optimism in a very long time.

What would you say to people who want to know more about ARVs for prevention?

The Centers for Disease Control & Prevention has a great deal more information about PrEP on its web site. To learn more, visit: www.cdc.gov/hiv/prep. For more information about the actual study, you can visit: www.helpfighthiv.org/prepare.htm. Individuals who are wondering if PrEP may be an option for them should consult their physician.




This article was provided by San Francisco AIDS Foundation. Visit San Francisco AIDS Foundation's Web site to find out more about their activities, publications and services.
 
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Reader Comments:

Comment by: Bobby (Cleveland, OH) Sat., Apr. 23, 2011 at 2:57 pm UTC
There's only so much money to go around, and we're wasting it on those who have options but would prefer dangerous bareback sex. Oh, excuse me, "natural sex". Whatever. Neither I nor anyone I know who got this disease ever did anything stupid enough to have benefitted from prep. We made the kind of mistakes that aren't preceded with a handful of pills.

I'm interested in ending this epidemic for EVERYONE, not just those who choose to put themselves in the line of fire. Rational self interest in the face of the misallocation of resources isn't "puritanism", its normal. Frankly, its healthy for us, and for society as a whole.

Its absolutely pathetic that there is so little consciousness amongst those with HIV that we don't even flinch while funds are diverted to preserving the online/bathhouse bareback "neg, ub2 crowd" while vaccine and especially cure funding remain almost nonexistent.

Screaming "puritanism" and "homophobia" sound damning, but they distract from the real issue at hand. Unless we intend to spike the water supply with this crap, this is only going to help those who choose to screw in risky situations without condoms. We're protecting the people who least deserve it. We're protecting those who have plenty of other options on the table over MILLIONS who are consigned to misery and an early grave. Screw that, I deserve a cure more than they deserve to spend the weekend in a sling at some bathhouse having "good, guilt free" sex.

My reaction isn't "puritanism". Its fair, its honest, and its real. Stop trying to slander my reaction into some sort of idiotic "fear of sex" and dont even TRY to pretend that I'm insinuating anyone else should get or deserves this virus. This is about the allocation of resources, public and private, and I'm rightfully angered. I've not heard any realistic scenario where highly expensive, tempermental and time sensitive pharmaceuticals are more easily accesible than condoms.

[This comment has been moderated to remove profanity and personal insults.]
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Comment by: Bobby (Cleveland, OH) Tue., Feb. 1, 2011 at 4:24 pm UTC
I'm so horrified that we're spending our money allowing willful barebackers to cultivate resistant strains of HIV and buy their way out of infection while thousands languish on ADAP waitlists and MILLIONS lack access to drugs at all. This is such a vile use of public money and time, and the fact that we're ensuring that only those with proper medical connections (ie a doc willing to prescribe off label), money to burn (because your insurance company might not cover it) and a willingness to put themselves in harms way for the thrill of bareback sex will benefit, makes it even more disgusting.
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Replies to this comment:
Comment by: John Eisenhans (St. Louis, MO) Thu., Feb. 24, 2011 at 6:54 pm UTC
"Bobby" is early one of those folks who is not the least bit interested in ending the HIV epidemic, but is only interested in ending sex. What we need, as much as a cure for HIV, is a cure for Puritanism, homophobia and sexphobia. Portraying people who have sex (that's what barebacking used to be called) as depraved or irresponsible is absurd - none of us would be here without barebackers. Of course, what they really mean is that their condemnation only applies to those having recreational sex, especially gay sex.

Truvada is only expensive because we allow it to be. In India, the generic version costs less than $100 per year. Why? Because the Indian government decided that the lives of their citizens were more important than drug company profits. They told Gilead to shove their patent and licensed the manufacture of the generic to local companies. We have to force AIDS profiteers to sell at a reasonable price, or lose control of their drug altogether.

Both Bobby and Mr. Gibson misrepresent the facts. There is no evidence that barebacking or using PrEP will create drug-resistant HIV strains. There is evidence that using PrEP as directed can be as effective as using condoms. Both work less well when they remain in the box on the shelf in the medicine cabinet. In fact, given that PrEP can prevent nearly all new HIV infections and ARV therapy can prevent someone who is already infected from transmitting HIV, the possibility exists, at least in theory, that the last new infection could already have occurred. In other words, except for those already infected, the whole epidemic could now be over.

But that would cost jobs and profits, and it would mean that people might go back to having joyfull, fearless, healthy sex. We certainly can't allow that.

[This comment has been moderated to remove profanity and personal insults.]
Comment by: Randy (Mitchrandall2000@gmail.com) Sat., Apr. 30, 2011 at 6:54 pm UTC
"There is no evidence that barebacking or using PrEP will create drug-resistant HIV strains"

Of course there is no "evidence". We've never tried anything like it before with antiretrovirals. We're in uncharted territory, and anytime we're in uncharted territory, we work with previous experience and reasonable projections. What sort of "evidence" are you looking for? Common sense and the laws of natural selection basically tell us that if PrEP comes to replace condoms, drug-resistant strains will proliferate. We've seen nearly identical scenarios played out with antibiotic usage, and the evidence in those cases points to the proliferation of resistant strains. What epidemiological or biological model do you draw upon to conclude that widespread antiretroviral-based prophylaxis will be unique in disabling the laws of evolution and preventing the rise of resistant strains?


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