September 7, 2011

September 7, 2011
Preparing For PrEP

Welcome to another day in my life. Today is Wednesday and we have almost made it through the middle of another work week. I hope you are having a safe and great week so far. It has been a very busy one for Dab the AIDS Bear and me.

Now you have heard me talk about PrEP before in my blog and I would like to discuss the issue again today. This is because of a recent conference call of which I was included.

Community HIV prevention leaders are trying to figure out what role, if any, pre-exposure prophylaxis (PrEP) might play in helping to rein in the number of new HIV infections that occur each year. Those questions and passions were on display at a lively and free-flowing forum last week at the National HIV Prevention conference in Atlanta.

PrEP uses antiretroviral drugs to protect from initial HIV infection. IPrEx, the first study proving the concept, was published last November. It showed that high risk gay and bisexual men who took the combination therapy Truvada as directed were 91 percent less likely to become infected with HIV compared with those who received a placebo. A subsequent study in heterosexuals also showed protection.

Further studies are needed to move beyond this proof of concept and figure out how PrEP might work in the real world what at risk groups might benefit the most from this expensive form of prevention and how programs might be structured to achieve the best results.

Dr. Grant Colfax, HIV prevention director at the San Francisco Department of Public Health, said the situation requires a paradigm shift in thinking similar to that which took place a decade ago prior to the large-scale rollout of treatment in sub-Saharan Africa.

"Building new systems of delivery in isolation just to provide PrEP is not a sustainable option," Colfax said. "Moving forward the question is, where are the sites where this is most likely to be delivered? Is it STD clinics, HMOs, primary care settings? How do we integrate it into a medical structure that is sustainable over time?"

Representatives from other San Francisco-based agencies were also in attendance at the forum.

"One of the fears I have is that PrEP will be looked at as this thing that is being put upon given populations rather than something that the populations themselves are asking for," said David Evans with Project Inform. "That is particularly sensitive in some communities," he said alluding to the legacy of suspicion that remains within the African American community from the Tuskegee syphilis experiment, in which federal public health officials studied the natural progression of untreated syphilis in poor, rural black men who thought they were receiving free health care from the government.

"We know what [PrEP] looked like in the IPrEx study but we don't know what it is going to look like in the real world," added Evans, who encouraged people to start having these discussions with the community and not "squander opportunities" to help shape the definition of what PrEP is.


The National Institutes of Health's Carl Dieffenbach fears "that PrEP, even in San Francisco, will not reach the people who will truly benefit from it" because people at highest risk for infection often do not get tested.

Testing is key to the use of PrEP because the drugs used probably are not sufficiently potent to completely suppress the viral load of someone already infected, and resistance will develop. Thus, testing negative is a prerequisite for using PrEP; those who test positive will be directed into care.

But testing also is a barrier to using PrEP. Dieffenbach asked, "Is it going to be so medicalized that it will end up being like a prescription where people just can't or won't fill it? We need to find a way of normalizing this, as radical as that sounds."

A participant from Washington, D.C. said physicians' views might be another barrier. "My doctor has told patients that he would not consider prescribing PrEP to anyone other than a person who was in a serodiscordant relationship. I guess because of fears of not using it properly."

"My big fear is that we are going to see rates of HIV go up because people are going to think this is the magic pill," said a man from New York's Gay Men's Health Crisis. That could be the result of poor adherence to the drug and/or an increase in risky behavior.

Perhaps the most commonly expressed theme was that inequitable access to PrEP might further worsen existing health disparities. Blacks are 13 percent of the U.S. population but about half of those infected with HIV.

Others supported the concern of a women from Miami who argued, how can one justify spending money on PrEP when more than 9,000 people are on ADAP waiting lists for drugs to treat their existing infection.


"My greatest hope is that [PrEP] ignites the HIV community on fire. It is one of the most radical, new HIV prevention technologies and approaches that has come along in 30 years," said Carey Johnson with the Fenway Institute in Boston. "My fear is that this is not happening, and I really wish I knew why."

Others said people are waiting to see how it will work.

"We've had a handful of people ask about PrEP; those who did were likely to have a seropositive partner or were in the IPrEx study," said Steve Gibson with Magnet, the San Francisco health center aimed at gay men. "People are waiting to see what's next. How it can be integrated into their lives."

People also talked about the need to generate interest and cost concerns.

"I think it is odd we are lamenting that no one comes to our clinics asking for PrEP. Well, we haven't told them about it, so why are we surprised?" said New York City physician Wafaa El-Sadr. "It is incumbent upon us to generate the interest. We do it for other interventions."

"I know of five to 10 people on PrEP locally, all of whom are discordant couples, all of them have insurance," said Joanne Stekler with the University of Washington. She sees cost as the major inhibitor on interest. "If you took away the costs issue, and maybe the adherence issue to a little degree, everyone would want to be on PrEP."

The discussion on PrEP will continue. What are your thoughts? Drop me a line and let me know.

Until we meet again; here's wishing you health, hope, happiness and just enough.

big bear hug,

Daddy Dab