PrEPping for the future

Posted on 28 Nov 2014 at 7:00am

DFW’s two AIDS agencies with medical clinics differ on PrEP, but their actual approaches aren’t really that different

Truvada.PrEP

 

DAVID TAFFET  |  Staff Writer

Maybe the two sides in the fight over Pre-Exposure Prophylaxis aren’t so far apart after all.

AIDS Arms recently issued a pro-PrEP policy, while AIDS Healthcare Foundation restated its long opposition to Pre-Exposure Prophylaxis. But both sides’ positions are much more nuanced than the basic pro-or-con dichotomy would allow.

John Carlo, executive director for AIDS Arms, which operates clinics in Oak Cliff and South Dallas, noted that PrEP — a treatment regimen involving dosages of the HIV medication Truvada for individuals who are HIV-negative but considered at high risk for contracting the virus — has proven so effective two studies were ended early.

“We have four years of evidence it works effectively,” he said.

But AHF argues that PrEP will not work on a community-wide basis because of consistently poor adherence by study subjects. Also the Centers for Disease Control, which changed its wording from “unprotected sex” to “condomless sex,” ignores the transmission of other STDs. AHF officials point out.

AHF operates clinics around the world including one at Medical City in Dallas and another next to AIDS Outreach Center in Fort Worth.

But neither side is arguing an “everybody-or-nobody” strategy.”

“Thoughtful providers will see the gray,” said AHF spokesman Ged Kenslea.

That echoes the nuanced approach taken elsewhere around the country.

Dr. Demetre Daskalakis, the former medical director of HIV services at Mt. Sinai Hospital in New York, is a staunch proponent of PrEP. But he said, “I would say personally, in my practice, I prescribe Truvada for pre-exposure prophylaxis, and about 50 percent of the people that present to me asking for Truvada, don’t get it, that they get other interventions and other things that I have to offer them to prevent HIV.”

Doctors at the two local agencies have prescribed Truvada for prevention use a limited number of times. Truvada was chosen as the drug to test as a preventive medication because it has the fewest side effects.

Carlo said in some cases Truvada causes nausea (especially during the first few days of usage), fatigue, increased risk of fractures and rare kidney damage, especially with certain pre-existing conditions. Kenslea added diarrhea, gastrointestinal issues and liver damage as other possible side effects.

Carlo said the CDC put out a good tool to decide who can benefit the most. “Many who will want it may not be indicated,” he said.

Carlo used as an example a long-term sero-discordant couple. If that couple has been successful in not transmitting the virus from the positive to the negative partner, what they’re doing works and there’s no need for the negative partner to begin a drug regimen, he said.

But newer sero-discordant couples may be good candidates, Carlo said. And if the positive partner is on medication but doesn’t consistently show a zero viral load, the negative partner may consider PrEP. Those having unprotected sex with multiple partners would also be indicated for the medication, Carlo said.

Carlo said a good PrEP program involves more than just taking the pill. He recommended doctor visits every three months that include screening for other STDs and regular discussions of safe sex in general.

Carlo said studies have shown that “If you’re in a PrEP program, your condom use goes up because you’re taking care of yourself.”

Carlo said he sees PrEP as a part of HIV prevention, a way to reduce infection rates and part of how to end the epidemic.

Kenslea agreed taking Truvada regularly is only part of an effective PrEP program. But he said he thinks the number who would participate in the regular check-ups, STD and liver function tests and discussion of condom use is low.

Carlo noted an interesting statistic about who’s on PrEP: Half of those taking Truvada for prevention are women. He said that’s likely because women are more inclined to go to a doctor regularly and discuss sex with their doctor.

But in a society that discourages gay men from coming out and encourages them to marry women, those closeted gay men married to women are more likely to have sex with men on the side, never participate in a discussion of safer sex and then expose their wives to the virus.

Kenslea said his organization’s main objection to PrEP centers on the CDC’s new proposal to scale up from the current 6,000 HIV-negative people on Truvada to a half million.

“We’re opposed to community-wide intervention,” Kenslea said.

He said those most likely to be compliant probably need the drug the least, but “We can’t even get people who are HIV-positive to take their pill.”

Kenslea said younger gay men are less likely to remain compliant because they don’t have the frame of reference of so many of their friends dying from AIDS.

Kenslea said he also fears an increase in STDs among those taking the pill and no longer using condoms.

While the Truvada regimen takes several weeks before it provides a good level of protection, daily adherence isn’t necessary to get good coverage, Carlo said.

Kenslea said studies showed that even those in tests who knew they were getting Truvada didn’t have high compliance even though they were receiving the drug free and being paid to participate. The group’s overall efficacy dropped to 49 percent, lower than the level needed to provide protection.

Kenslea bristles when he hears people talking of Truvada as “the new party drug.” He said he has seen people advise taking the drug for three days before going to the White Party, claiming they’ll be safe. No test shows that level of usage works at all.

Kenslea said doctors in his agency’s clinics do prescribe PrEP. But, “It’s on a case by case basis. It’s a compliment to condom use.”

Both sides cited the $1,000-a-month cost as putting PrEP out of the reach of most people without insurance. Carlo said insurance companies will pay for the drug but put obstacles in the way.

Carlo said he’d like to find a way to make PrEP available to some AIDS Arms clients.

“Studies are very compelling that it works,” Carlo said. “It’s proven to be effective.”

This article appeared in the Dallas Voice print edition November 28, 2014.

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