PrEP for the Future

One patient reports a nurse told him she had never heard of it. Another doctor said the medicine was "just for porn stars." A third patient, though, says knowing a potential partner is on it is the only way to go.

They're all talking about pills known as PrEP, short for pre-exposure prophylaxis, which research says can prevent the spread of HIV more effectively than most other options to date.

Condom use and making "less risky" choices still top the recommendations by the Centers for Disease Control and Prevention, yet PrEP is also now on that list. Some of the same drugs that helped make the virus virtually undetectable and un-transmittable in HIV-positive individuals have been approved by the US government for a preventative regimen.

All three of the true stories above are from men in Santa Fe. But Dr. Joel Gallant, head of the HIV, AIDS and hepatitis C treatment and research programs for Southwest Care Center, says that as another World AIDS Day rolls around on the calendar (it's today, Dec. 1), the message about PrEP is getting out.

"There is just no excuse for getting HIV anymore," Gallant tells SFR. "And while the politically correct thing is to tell everybody to use condoms, the reality is it's not happening, and we have this other tool that can prevent a lifelong disease."

Most insurance companies cover the prescription, which goes by the brand name Truvada, as does Medicaid, and in the absence of all those options, the drugmaker Gilead Sciences, Inc. also has a program that defers the cost for patients.

Gallant says he's seen a marked uptick in Santa Fe patients who ask for PrEP, and that trend reflects a national movement.

Based on data collected with the help of insurance companies, Truvada's manufacturer reports more than three times as many patients used PrEP in the first quarter of 2015 compared to a year earlier, according to Dr. Trevor Hawkins, the Southwest Care founder who left Santa Fe this year to work as a senior medical director for medical affairs at Gilead. While it's difficult to pin down the exact number of individuals using the medication at a particular time, Hawkins says the exponential increase is notable.

"Our understanding is that it's rapidly increasing. PrEP was approved for use in 2012, and it was slow to start, but now the numbers are picking up," Hawkins says.

Awareness about PrEP has really taken off by word of mouth, Gallant says.

"There is a huge discussion of PrEP on social media, and it used to be very negative, and now it has become much more positive," Gallant says. "There have been just study after study showing how effective it is: the British PROUD study, the French Ipergay study showing virtually 100 percent effectiveness in people who are taking the medication." (The CDC, by the way, says that taking PrEP makes an individual 92 percent less likely to contract the virus than not taking it.)

The idea that doctors would admit the problem with condom compliance and instead talk about harm reduction is itself a sea change that first began with some of the same compounds being applied as a sort of "morning-after" pill for risky sex. The PEP regime (for post-exposure prophylaxis) is a three-drug combo that that, taken for a few weeks after exposure to the virus, is shown to be effective in preventing its acquisition.

Gallant says the most recent application, which uses two of the drugs from PEP, called tenofovir and emtricitabine, is a significant advancement. Yet there are still hurdles. A recent survey conducted for the CDC, for example, estimated that up to a third of US doctors don't know about PrEP or aren't willing to prescribe it. Gaycitynews.com quoted Dr. Anne Schuchat, the CDC's principal deputy director, as saying, "We need to work to ensure that clinicians are aware of PrEP. Doctors need more prep about PrEP."

A spokeswoman for Porter Novelli, the firm that conducted the survey, tells SFR that more data on doctor awareness and other issues from the research are set for release at the upcoming National HIV Prevention Conference on Dec. 7.

"The other point I think is really important that no one ever talks about is that the most effective  forms of prevention until PrEP were in the control of the person least likely to be infected. So you think about a man who is wearing a condom because he is engaging in insertive anal or vaginal sex, he's not the one at risk, it's the woman or the man on the bottom who is at risk. The prevention is a little bit out of their control because they have to trust the insertive partner to be wearing the condom. And that is also true of treatment as prevention. You have to rely on the person who is positive to be taking HIV medicines to prevent transmission, but you don't really have any control over that," he says. "PrEP suddenly puts prevention in the hands of the person who is the one at risk. And it's the only intervention that we have that does that, that empowers people who are at risk to prevent HIV rather than the other partner."

Gallant arrived in Santa Fe about two years ago but has worked in HIV and AIDS medicine since his residency in San Francisco in 1981. To learn more about PrEP, he invites visitors to the clinic's Harkle campus on the first Monday of every month.

Santa Fe Reporter