By Dana Van Gorder
In cities like San Francisco, where I sit, a relentless focus on increasing the number of HIV-positive people taking anti-retroviral medications early in infection has been primarily responsible for improvements in their health outcomes, and reducing HIV incidence. With new HIV cases numbering some 1,200 a year a decade ago, San Francisco now estimates that there will have been some 330 new cases in 2013. As a group of agencies develop a strategy for “Getting to Zero” in San Francisco, the plan’s architects firmly believe that PrEP could have an important effect on incidence, too.
The release this month of revised CDC guidelines for the use of PrEP constitutes a critically important and valuable reinforcement of the evidence that the following groups should consider using PrEP: serodiscordant couples; gay and bisexual men who have had sex without a condom or been diagnosed with an STI in the previous six months; heterosexual men and women who do not regularly use condoms during sex with partners of unknown HIV status; and active injection drug users. The guidelines provide solid advice for medical practitioners about when to offer and how to provide PrEP to those who choose it, as well as strategies for supporting adherence to taking Truvada daily.
Indeed, two issues have been of particular concern to community members, providers and policy makers about PrEP. The first is that patients will not take Truvada daily as required in order to be effective; and the second, that PrEP will further discourage condom use among those who use it. What research, programs and policy are needed to address these issues and advance PrEP as one sound prevention option among others?
Perhaps the most important support for adherence would be the identification of PrEP medications that are long-lasting rather than requiring daily use. In fact, clinical trials are beginning on injectable PrEP agents that could last in the body for up to three months. Additionally, research from current PrEP demonstration projects will begin to help us understand whether adherence is in fact a problem among participants, and what strategies are successful in supporting it. That research will also tell us whether reduced condom use is occurring, and what strategies might address it, as well.
The current level of stigma attached to PrEP in the gay community and among medical providers must be eliminated. PrEP is an evidence-based form of harm reduction for people who are not using condoms consistently or at all during anal or vaginal sex. No one should be shamed for choosing it. Some of the same people who would support a woman’s right to use the form of contraception that best meets her needs oppose PrEP. So, too, people who would argue that condoms should be made available to teenagers because we must face the reality that many are sexually active. These folks need to rethink their position on PrEP in order to be consistent.
Far too few people who could benefit from PrEP are even aware of it. The CDC is launching a new social marketing effort targeting gay and bisexual men that includes discussion of PrEP. It and other funders should assure a multifaceted approach to community education about this intervention, with emphasis on young African-American gay and bisexual men, transwomen, and HIV-negative women in serodiscordant couples who want children. Many medical providers also badly need enlightenment about the CDC’s PrEP guidelines. The CDC has conducted one set of grand rounds on PrEP. It should add greatly to these efforts. HIVMA is conducting education for its members. So, too, should other membership organizations of medical providers, including the AMA, NMA, and GLMA.
While PrEP is being covered by many private insurers and most Medicaid programs, it is critical that advocacy continue not only for coverage, but for ease of access. Some payers require Prior Authorization or Treatment Access Requests (TARs) to initiate PrEP, slowing access or discouraging it altogether. California’s Medi-Cal program recently agreed to eliminate TARs for PrEP, and the three agencies that advocated for this - Project Inform, the San Francisco AIDS Foundation and AIDS Project Los Angeles - believe this will lead to increased uptake.
Finally, while understandable focus has been placed on encouraging HIV-positive people to sign up for newly available health care insurance as a result of the Affordable Care Act, it would be very important to develop programs that support those HIV-negative people who are targeted for PrEP to enroll in coverage in order to access both biomedical and other prevention services.
Posted By: Dana Van Gorder, Executive Director, Project Inform - Friday, May 23, 2014