Pill to fight HIV stirs controversy among gays

BY ERYN BROWN AND ADOLFO FLORES
LOS ANGELES TIMES (TNS)

It would have seemed the stuff of fantasy in the dark days of the 1980s, when an AIDS diagnosis was tantamount to a death sentence: a pill, taken daily, that could protect against HIV infection.

Truvada, a newly FDA-approved drug to help prevent HIV infection, is among the AIDS drugs that fill the shelves at the pharmacy at the Whitman-Walker Clinic on July 19, 2012, a Washington, D.C.-based community health center focusing on HIV/AIDS care and lesbian, gay bisexual and transgender care. (ASTRID RIECKEN/TNS)
Truvada, a newly FDA-approved drug to help prevent HIV infection, is among the AIDS drugs that fill the shelves at the pharmacy at the Whitman-Walker Clinic on July 19, 2012, a Washington, D.C.-based community health center focusing on HIV/AIDS care and lesbian, gay bisexual and transgender care.  (ASTRID RIECKEN/TNS)

But today, such a drug exists. The blue tablet, marketed as Truvada, has been available to people at risk of being exposed to HIV since 2012.

The pill can be highly effective — reducing infection risk by as much as 92 percent, according to the U.S. Centers for Disease Control and Prevention.

It could have a dramatic effect in Los Angeles County, where about 47,000 people are known to live with HIV.

Contracting the virus is no longer a death sentence because of a cocktail of drugs that suppress it, but the county still reports more than 1,000 new HIV infections each year.

“We want to bring HIV to its knees, and this will help,” said Mario Perez, who directs the county’s prevention program.

Called ‘party drug’
But the concept of using the pill — known in medical circles as pre-exposure prophylaxis — has stirred a surprising debate in the gay community, with some longtime activists calling Truvada a “party drug” that people will never take consistently enough to stave off infections. If not taken daily, the CDC warns, protection levels are lower.

Most notable among the skeptics is AIDS Healthcare Foundation President Michael Weinstein, whose organization recently launched a new advertising campaign urging the CDC to rethink its support for a communitywide prevention method that does not emphasize condom use first and foremost.

Those with a more sanguine view of the pill wonder why critics such as Weinstein’s foundation would dismiss any tool with the potential to decrease HIV infection rates, which are creeping up among young gay and bisexual men of color.

“There is a moral imperative to make this available for folks who think it’s the right approach,” Perez said. “We’re big fans in giving people options to achieve their goals, with no judgment.”

Key part of strategies
Public health officials throughout the U.S. have already made the approach a key part of their official HIV prevention strategies. Last spring, the CDC added its stamp of approval when it released official guidelines on pre-exposure prophylaxis. In July, New York Gov. Andrew Cuomo put the method at the center of an effort to drastically cut the numbers of new HIV infections in his state by 2020.

Truvada combines two drugs that have been part of the anti-retroviral cocktail taken by HIV-positive patients for years. The medicines, tenofovir and emtricitabine, work together to block an enzyme called reverse transcriptase that allows HIV cells to multiply. In addition to suppressing HIV that is already in the body, the drugs can also prevent the virus from gaining a foothold initially.

Use with condoms
At $13,000 a year, Truvada is expensive, but it is covered by most insurance plans.

In early November, Gilead Sciences, the company that manufactures the drug, reviewed retail pharmacy records from a little more than half of U.S. pharmacies that dispensed Truvada between Jan. 1, 2012, and March 31, 2014, and found that 3,253 people in the U.S. started the prevention regimen during that period.

Advocates of pre-exposure prophylaxis blame the slow increase at least in part on moralizing by people such as Weinstein.

The crux of critics’ concern is that offering gay men another way to block AIDS infection will undermine a long-standing push in the community to promote condom use, which is known to also prevent the transmission of HIV and STDs.

CDC guidelines for administering pre-exposure prophylaxis stipulate that Truvada should be used with condoms, not instead of them. But some, most notably Weinstein, say that men won’t bother with condoms if they believe they are protected by a pill.

“You have to be really paranoid about your health to wear a belt and suspenders,” he said. “If the culture shifts to unprotected sex because of the campaign to promote Truvada, then (HIV) rates will go up.”

Risk reduction rate
Weinstein and others have noted that overall risk reductions in clinical trials for pre-exposure prophylaxis were lower than the CDC-cited 92 percent. The so-called iPrEx study, for instance, reported that people who took Truvada experienced only a 44 percent reduction in HIV infection risk.

The overall risk reduction rate was low because many participants in the study did not take their medication as directed, scientists say.

Weinstein argues that others will also fail to use the drug correctly, leading to a rise in new HIV cases and other sexually transmitted infections.

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