Questions about Truvada (PreP)

[hotatlboi]

As I'm sure many of you know, one of the highest rates of HIV infection today is in young gay men. As someone in that group, I was relatively surprised to find out that:

1. There is a pill (Truvada) that, when taken daily, can reduce the risk of HIV infection in HIV negative gay men by over 90% (iPrEx trial).
2. Relatively few people on this pill experience any serious side effects.
3. While there was some uncertainty about coverage initially, almost all major insurance companies have agreed to cover the pill for PreP treatment.

Despite this, relatively few people are taking it.

Why is this not being discussed more in our community?

Is there something I'm missing here?

Obviously one still has to be careful in their sex practices, but it sounds like this could be a great thing if it can reduce the rising HIV infection rate we have seen recently.

 

[nafhoosier]

Forget it.

Use a condom.

There are still no definitive figures on the effectiveness of PreP... I wouldn't risk it.

If you don't want HIV- use a condom. Every time.

Relying on PreP can backfire.

Why is it not being discussed more in our community? Personal responsibility. If you want to bareback, that's your choice. But accept that your decision is likely to catch up with you, and you will get HIV.

 

[bankside]

Great article on this very recently in Slate.

http://www.slate.com/blogs/outward/...men_should_take_pre_exposure_prophylaxis.html

The second thorny problem raised by Truvada is the condom conundrum. Those who slam Truvada tend, in the same breath, to praise condoms like it’s 1986. But condoms—despite being a favored solution of the gay old guard—present serious problems of their own. Only 1 in 6 gay men use condoms unfailingly, and sporadic use provides minimal defense against HIV infection. Even more troublingly, condoms don’t work as well during anal sex: With perfect use, they’re only 86 percent effective against HIV during anal intercourse. (With perfect use during vaginal intercourse, they’re 98 percent effective.) Add to this the fact that unprotected bareback sex just feels better, and you’ve got a strong case for combining Truvada with condom usage as an extra protection against infection.

Condoms aren't a magic wand.

Bottom line, if you want to have an active sex life with random strangers, you are at high risk of getting a disease or passing one on, whether you use condoms or truvada.

The thorny problem not being dealt with by the gay community (including that article I linked to btw) is that random stranger sex doesn't work.

 

[hotatlboi]

Use a condom.

It is supposed to be used with condoms, yes.

There are still no definitive figures on the effectiveness of PreP

False. There was a carefully controlled study that produced very statistically significant results. Was there something you did not understand about the study?

 

[hotatlboi]

The thorny problem not being dealt with by the gay community (including that article I linked to btw) is that random stranger sex doesn't work.

Of course, having one partner that you are committed to is the best situation. But for those of us who haven't met that person yet, another method that seems to be effective at HIV prevention (in addition to condoms) is a good thing imo.

 

[hotatlboi]

Why is it not being discussed more in our community? Personal responsibility. If you want to bareback, that's your choice. But accept that your decision is likely to catch up with you, and you will get HIV.

This sounds like something an "abstinence only" sex education advocate would say. It's basically saying "I'm not going to tell you about an effective method of disease prevention when it comes to sex, because I don't like the kind of sex you are having. And if you get a disease or become pregnant, well then you should have taken personal responsibility".

I'm not saying this means that condoms are no longer needed. That is nonsensical. This pill is obviously not 100% effective, and there are still plenty of other diseases you can get besides HIV if you don't use a condom. What I am saying is, I think people should at least know about this as another possible method of prevention that is available, there doesn't seem to have been much communication about it within the gay community from what I can tell. And with the rising rates of HIV infection we have seen in recent years, we need to be using every weapon available against it.

 

[hotatlboi]

Great article on this very recently in Slate.

I read that earlier, it was part of my motivation for posting this thread.

I found this section particularly poignant.

But a concern about memory isn’t really what’s holding back Truvada from becoming a lifesaver in America. The problem, instead, lies in a generational dispute between older gay men, who lived through the worst of the AIDS crisis, and younger ones, who often see HIV as little more than a chronic but manageable disease. Gay men in the 1980s fought for their lives to get the government to expand access to and education about condoms. It was a noble struggle, but also an insufficient one. Today’s AIDS landscape reveals that an unyielding devotion to condom usage isn’t enough to halt the spread of HIV. It takes a variety of safe-sex practices to shield gay men from infection, and Truvada should be a linchpin of that strategy. Given the seemingly unstoppable drop in condom usage among gay men, this is no time for ideological disputes or intergenerational conflict.

I couldn't agree more with this.

It almost seems like some older guys are bitter because they had to live though the period when you would die if you didn't use a condom, so they don't want something like this to exist. They would rather us youngins learn some "personal responsibility" (like the one post above) if we slip up and forget to use a condom. This kind of attitude is absurd and counterproductive to what should be the real goal, which is eliminating HIV entirely by any means we can. If this pill can help do that, then it is a good thing.

I didn't live through the all my friends dying of AIDS era, so I admit that I lack the perspective on it that some older guys have. But what I do have is a passion for science, and what it seems to me that we have here is a drug that can seriously help in the fight to eliminate the scourge of HIV in our community. The CDC has said that if the current rate of infection among young gay men continues as it has been, then half of us will be positive by the time we are 50. I don't want that for myself or for others of my generation.

 

[nafhoosier]

This sounds like something an "abstinence only" sex education advocate would say. It's basically saying "I'm not going to tell you about an effective method of disease prevention when it comes to sex, because I don't like the kind of sex you are having. And if you get a disease or become pregnant, well then you should have taken personal responsibility".

I'm not saying this means that condoms are no longer needed. That is nonsensical. This pill is obviously not 100% effective, and there are still plenty of other diseases you can get besides HIV if you don't use a condom. What I am saying is, I think people should at least know about this as another possible method of prevention that is available, there doesn't seem to have been much communication about it within the gay community from what I can tell. And with the rising rates of HIV infection we have seen in recent years, we need to be using every weapon available against it.

You're certainly not fooling me, and I hope you're not fooling anybody else with this BS.

Similar to abstinence only education? Thanks for the LOL not only of the day, but of the month.

I don't mean to be mean or harsh on you (but if you think I am, so be it), but you sound very naive and a little ignorant. No, PrEp is not meant to be used with a condom (seriously? Why would you need to take PreP when you use a condom, that is nearly 100% effective when used correctly and not breaking). PreP is a fresh, new experiment that MAY be effective according to a study, but condoms are still the best option. Why risk it? And you mentioning in your previous post that the older generation is "bitter" because they had to "live through a period when you die if you didn't use a condom, so they don't want something like this to exist". Dude, people STILL die from HIV and AIDS, but they are living decades longer. And those that are living decades longer live a very rough life. You don't seem to be grasping the seriousness of having HIV. Yes, they live lives similar to ours (I have Poz friends). They don't let their diagnosis hold them back. But they face many challenges I don't, daily challenges that are rough and hard on them and that won't ever go away. Are you really telling me the virus isn't as serious as it used to be? Oh, and they take personal responsibility for their diagnosis btw. Outside of a betrayal of trust in a monogamous long term relationship or rape, you SHOULD take responsibility for not using a condom. Your health when you have consensual sex is YOUR responsibility. Period.

PreP is expensive (like PEP), certainly more expensive than condoms. Why should we inform gay men (many of whom can barely afford buying condoms, yet alone pricey HIV medication), of a new experimental drug that is expensive and relatively hard to get, and risk confusing them and having them just not use anything altogether. That's effective in wiping out HIV to you? No, insurance companies should NOT cover PreP (PEP is another story). There's no reason why the government should be spending tax dollars on someone who wants to have risky sex with strangers. Condoms can be bought easily at drug stores, and are now handed for free at most health clinics all over the country.

The gay community has a sound anti-HIV plan already in place .Educating people on how HIV is really spread, advocating 100% condom use in all situations outside of trusting monogamous relationships, getting people tested for FREE so they know their status and handing out FREE condoms, and getting people who are diagnosed on treatment as fast and affordable as possible (which insurance companies SHOULD cover).

To be honest, bare backers don't really bother me (most of them accept they'll get HIV due to their choices, aka personal responsibility). I myself always use protection during sex outside of a monogamous relationship and do everything right that is proven to prevent HIV infection as much as possible. I know that their choices won't effect me because I'm smart and safe. What bothers me are people who come up with excuses not to use condoms but still "think" that there are ways around getting HIV, such as what you are advocating. Once again, its really what ends up getting people infected in the long run.

 

[nafhoosier]

Great article on this very recently in Slate.

http://www.slate.com/blogs/outward/...men_should_take_pre_exposure_prophylaxis.html



Condoms aren't a magic wand.

Bottom line, if you want to have an active sex life with random strangers, you are at high risk of getting a disease or passing one on, whether you use condoms or truvada.

The thorny problem not being dealt with by the gay community (including that article I linked to btw) is that random stranger sex doesn't work.

There has never been a case of HIV being transmitted through a condom that was used correctly and didn't break. If there has been, please let me know, I'd be very curious.

Nothing is a guarantee of anything, and I myself don't like to have sex with random strangers. But there always will be tons of people, gay and straight, who do. And condoms are the best tool we have to prevent people who do that from getting HIV (that's what we're talking about here).

So this idea of saying sex with random strangers doesn't work... good luck with that. Obviously I agree with you on the idea, but people will do that anyway.

 

[RaKroma]

PREP as mass HIV prevention strategy is bogus fantasy that's borderline dangerous in the way it has been advertised by big pharma and excited porn producers. The only thing PREP talk in gay media is doing is confusing uninformed guys into believing that it's some morning before pill that keeps you safe from HIV. And I have heard stories where guys actually have done this in practice. The reality is the few studies show mixed results between 44%- 90% prevention efficacy rates. The 90% was achieved by some group of men that consistently took these pills daily. The people that do not take PREP daily lose their protection and no study can show yet by how much and whether there are long term serious side effects like bone mass loss and kidney stones.

Now, PREP will be useful to some demographic of men, but as a mass strategy to reduce HIV rates, it's laughable. Guys can't afford to get regular full panel STD screens and we expect masses to use daily pills that cost roughly $13,000 a year? Go research how much insurance companies are actually covering the cost of Truvada for HIV negative people. You are still left paying hundreds of dollars per month. And do we really expect people to be on a daily regimen consistently? There are cheaper solutions that have better efficacy rates.

 

[hotatlboi]

I don't mean to be mean or harsh on you (but if you think I am, so be it), but you sound very naive and a little ignorant. No, PrEp is not meant to be used with a condom (seriously? Why would you need to take PreP when you use a condom, that is nearly 100% effective when used correctly and not breaking).

Nope, you're the one who just displayed your naivete on this subject.

It absolutely is meant to be used with condoms.

It's clear you haven't read or understood the most basic info about this topic.

Here's a good page for you to start with.

www.truvadapreprems.com/

The gay community has a sound anti-HIV plan already in place.

No it doesn't. As I tried to communicate, even after years of effort in educating everyone about safer sex practices, the rate of HIV infection among gay men has not decreased significantly, and it is actually increasing again in some demographics. The increase is especially significant in young gay men.

This is another potential weapon against HIV that can and should be looked at.

 

[hotatlboi]

PREP as mass HIV prevention strategy is bogus fantasy that's borderline dangerous in the way it has been advertised by big pharma and excited porn producers. The only thing PREP talk in gay media is doing is confusing uninformed guys into believing that it's some morning before pill that keeps you safe from HIV. And I have heard stories where guys actually have done this in practice. The reality is the few studies show mixed results between 44%- 90% prevention efficacy rates. The 90% was achieved by some group of men that consistently took these pills daily. The people that do not take PREP daily lose their protection and no study can show yet by how much and whether there are long term serious side effects like bone mass loss and kidney stones.

In other words, intelligent people who use it effectively can obtain effective prevention, those who can't don't. As I looked into this, that was the debate over whether it should be marketed for prophylactic use. In the end, they decided that making it available to those who could use it effectively was worth it.

Now, PREP will be useful to some demographic of men, but as a mass strategy to reduce HIV rates, it's laughable. Guys can't afford to get regular full panel STD screens and we expect masses to use daily pills that cost roughly $13,000 a year? Go research how much insurance companies are actually covering the cost of Truvada for HIV negative people. You are still left paying hundreds of dollars per month. And do we really expect people to be on a daily regimen consistently? There are cheaper solutions that have better efficacy rates.

The bolded is really all I was saying with this thread. I'm aware and agree with you that this is not the end of HIV nor is this drug attainable or usable by everyone. I'm just saying that I think people should be aware of it. They can decide for themselves whether it makes sense for them to use.

 

[bankside]

There has never been a case of HIV being transmitted through a condom that was used correctly and didn't break. If there has been, please let me know, I'd be very curious.

That's a bit like saying there has never been an ocean liner being sunk in the Atlantic that was piloted correctly and didn't strike an iceberg.

The gay community has a sound anti-HIV plan already in place.

If that were true, HIV would have disappeared by now. India can eliminate polio, but the gays can't manage to stop fucking each other to death.

This plan isn't sufficient:

Educating people on how HIV is really spread, advocating 100% condom use in all situations outside of trusting monogamous relationships, getting people tested for FREE so they know their status and handing out FREE condoms, and getting people who are diagnosed on treatment as fast and affordable as possible (which insurance companies SHOULD cover).

To be honest, bare backers don't really bother me (most of them accept they'll get HIV due to their choices, aka personal responsibility).

If you actually believe that, why wouldn't it bother you?

 

[KaraBulut]

Why is this not being discussed more in our community?

It's being discussed quite a bit.

The original studies of PreP were intended to look at serodiscordant relationships, IV drug users and high-risk populations in places like Africa where HIV is epidemic. The research that alludes to "90% reduction" is looking at these populations and estimating reduction rates. There's no way to do a controlled study where we attempt to infect someone with HIV, so these studies are trying to infer a probability.

Incidentally, the studies also say that if the person who has HIV takes antiretroviral therapy that results in a low viral load, the risk of transmission is greatly reduced. It makes more sense to use resources to treat someone who has HIV instead of putting resources into treating someone who is doesn't have HIV.

The pharmaceutical companies are always looking for new markets. They are putting out press releases about PreP which encourage extension of the studies to new markets. Check out their website- they are already pushing the drug for PreP.

Relatively few people on this pill experience any serious side effects

...compared to older drugs like AZT, DDI, DDC, etc, yes.

But there is still a number of people who experience gastrointestinal upset, diarrhea, nausea, loss of bone density, decreased kidney function, lipodystrophy...

One thing that is quite alarming is that studies of post-exposure prophylaxis (PEP) show high rates of non-compliance- either because the person couldn't afford the drug, couldn't tolerate the drug or they just didn't want to take a pill a day for 30 days. What's the likelihood of compliance when the drug is taken 365 days a year?

Is there something I'm missing here?

Yes- 30 day supply of Truvada is about $1300 (about $16,000 per year).

A box of 30 condoms is about $20.

Which is the better use of resources?

 

[bankside]

One thing that is quite alarming is that studies of post-exposure prophylaxis (PEP) show high rates of non-compliance- either because the person couldn't afford the drug, couldn't tolerate the drug or they just didn't want to take a pill a day for 30 days. What's the likelihood of compliance when the drug is taken 365 days a year?

This is really shaking. I'd have called myself an optimist in my politics and my daily life about the power of humans to stick together and make life better all around. But finding out people won't take a pill for 30 measly days to prevent the establishment of HIV really makes me want to say fuck'em they're on their own. Knowing mentors and friends who have died of HIV, and would have died willingly if that sacrifice would have made treatment possible for their friends in that generation, I cannot begin to say how offensive it is that people would not even do something so simple as just pop a fucking pill every day for a month.

 

[KaraBulut]

This is really shaking. I'd have called myself an optimist in my politics and my daily life about the power of humans to stick together and make life better all around. But finding out people won't take a pill for 30 measly days to prevent the establishment of HIV really makes me want to say fuck'em they're on their own.

The non-compliance rate for some populations has been as high as 40%.

There's some additional research needed but we think that there's a different reasons for the low compliance. In the case of sexual assault victims, PEP is a daily reminder of something that they probably want to forget. In the case of those who had a voluntary high risk exposure, it is probably part of the same reckless pattern. For others, the side effects are just too unpleasant.

The problem, of course, is that incomplete course of treatment increases chances of drug resistance.

 

[hotatlboi]

The original studies of PreP were intended to look at serodiscordant relationships, IV drug users and high-risk populations in places like Africa where HIV is epidemic. The research that alludes to "90% reduction" is looking at these populations and estimating reduction rates. There's no way to do a controlled study where we attempt to infect someone with HIV, so these studies are trying to infer a probability.

You don't need to do that. All you need to do is a controlled study in a population where you know the general rate of HIV infection. In your control group, you would expect about that same rate to take place. In your experimental group, if the medication is effective you would expect a drop in the rate of infection. That is what was found, with the efficacy varying considerably based on adherence to taking the medicine (in other words, intelligent people using it as directed). This is exactly the same type of study that found the major advances in the treatment as prevention strategy in serodiscordant couples.

Incidentally, the studies also say that if the person who has HIV takes antiretroviral therapy that results in a low viral load, the risk of transmission is greatly reduced. It makes more sense to use resources to treat someone who has HIV instead of putting resources into treating someone who is doesn't have HIV.

Why does it have to be either/or?

The pharmaceutical companies are always looking for new markets. They are putting out press releases about PreP which encourage extension of the studies to new markets. Check out their website- they are already pushing the drug for PreP.

Of course they are. And I completely agree that those companies push a lot of unneeded pills. But this is not a pill to prevent restless leg syndrome. HIV infection is a life changing event that significantly alters your future health prospects. If this use can help some avoid that, then its at least worth considering.

..compared to older drugs like AZT, DDI, DDC, etc, yes.

But there is still a number of people who experience gastrointestinal upset, diarrhea, nausea, loss of bone density, decreased kidney function, lipodystrophy...

Yes, and that's a valid point. This is not an ideal prophylactic drug. It is a heavy drug and its mechanism of action is very broad (since it was originally intended to treat the infection). However, I think people who would be using it for prevention would potentially be less likely to see these because most of the more serious side effects are associated with taking the drug over long periods of time. For someone using this as treatment, they have to take it (or something like it) for their entire lives. In the prevention context, you really only need to take it during periods of time where you are engaging in higher risk activity (i.e. not in a monogamous relationship and having sex with multiple partners).

One thing that is quite alarming is that studies of post-exposure prophylaxis (PEP) show high rates of non-compliance- either because the person couldn't afford the drug, couldn't tolerate the drug or they just didn't want to take a pill a day for 30 days. What's the likelihood of compliance when the drug is taken 365 days a year?

This is back to the "should we allow responsible people to have access to it when there are a lot of idiots who can't follow directions" question. I come down on the yes side of that, though I certainly understand there is disagreement.

Yes- 30 day supply of Truvada is about $1300 (about $16,000 per year).

A box of 30 condoms is about $20.

Which is the better use of resources?

Like bankside pointed out though, condoms are not completely foolproof. I've experienced condoms breaking during anal intercourse on more than one occasion. If you are not in a relationship and are having a lot of sex with different people, you are at risk even if you try and play it safe.

 

[nafhoosier]

That's a bit like saying there has never been an ocean liner being sunk in the Atlantic that was piloted correctly and didn't strike an iceberg.

As I said, feel free to dig, dig, dig and find a case of someone proven to get HIV from a condom that didn't break and was used correctly. I am waiting to be proven wrong on this statement. HIV does NOT penetrate through protected intact latex.

You're right about the condom breaking. That is a risk. And there is a risk in everything. But seriously, if you are saying that the plan I said is working isn't, what's your alternative solution? It seems like it is telling people who are single not to have sex. Do you REALLY think that'll work?

There's risk to everything. But if you use a condom correctly every time, the chances of you getting HIV are so dramatically reduced. No, I personally don't like the random hook up scene. But I don't feel like I have the right to judge a guy who does and uses condoms every time. I think that's the best strategy we can do.

What is your strategy then?

 

[nafhoosier]

If that were true, HIV would have disappeared by now. India can eliminate polio, but the gays can't manage to stop fucking each other to death.

Gay people have just as much of a right as straight people to hook up without being judged. You're married, you can have sex whenever you want. What are you going to say to lonely single people who have trouble dating and meeting others but get horny at times?

"Sorry, sex isn't just for you?"

 

[KaraBulut]

There's no way to do a controlled study where we attempt to infect someone with HIV, so these studies are trying to infer a probability.

You don't need to do that. All you need to do is a controlled study in a population where you know the general rate of HIV infection...

The comment wasn't about methodology. It was about ethics and results. Ethically, we cannot do a sound and objective controlled study about HIV infection in humans. So, for a pharmaceutical company to say that their drug reduces HIV infection rates by 90% is misleading and probably inaccurate.

Here's the findings from one of the studies reported in 2010:

METHODS

We randomly assigned 2499 HIV-seronegative men or transgender women who have sex with men to receive a combination of two oral antiretroviral drugs, emtricitabine and tenofovir disoproxil fumarate (FTC–TDF), or placebo once daily. All subjects received HIV testing, risk-reduction counseling, condoms, and management of sexually transmitted infections.

STANDARD PREVENTION INTERVENTIONS
Subjects who reported a recent unprotected exposure to an HIV-infected partner were referred for postexposure prophylaxis (at sites where such therapy was available), and the administration of a study drug was temporarily suspended. Vaccination against hepatitis B virus (HBV) was offered to all susceptible subjects.


RESULTS
The study subjects were followed for 3324 person-years (median, 1.2 years; maximum, 2.8 years). Of these subjects, 10 were found to have been infected with HIV at enrollment, and 100 became infected during follow-up (36 in the FTC–TDF group and 64 in the placebo group), indicating a 44% reduction in the incidence of HIV (95% confidence interval, 15 to 63; P = 0.005). ...

The researchers provided condoms and counseling for ethical reasons. If any research subject was known to be exposed to HIV during the study (n=21), they were pulled from the study and given PEP- another ethical consideration. And during the year, they still had 100 infections in a population of 2499 subjects and they still had 36 infections in the group that received the medication. And patients who were less that 90% compliant (i.e. did not take the medication daily as instructed) were 3.5 times more likely to be infected (n=8 vs n=28).

So, 2499 were studied for 1 year. 36 people in the group who received the medication were HIV+ at the end of the study (36/1224 = 2.9%) vs 64 in the control group who didn't receive the medication (64/1217=5.25%).