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May 23, 2014 2:14 PM   Subscribe

This month, the US Public Health Service released (PDF) the first comprehensive clinical practice guidelines for PrEP (Pre-Exposure Prophylaxis) which outlines the criteria for determining a person’s HIV risk and indications for PrEP use. (PrEP FAQ) The CDC states, "When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently." The FDA's approved drug — Truvada — that was previously approved for H.I.V. treatment in 2004, is now approved it for prevention of HIV transmission. (Truvada previously)

NYTimes: Are We Ready for H.I.V.’s Sexual Revolution?: The first is psychological. Doctors and policy makers need to admit that 30 years of the ABC mantra — abstain, be faithful, use condoms — has failed. Men generally hate condoms, their lovers usually give in, almost no one abstains, precious few stay faithful.

Slate's interview with Peter Staley: Because we don’t have the death and dying that forced a drastic change in sexual behavior among gay men in the mid-’80s, which was largely sustained until the early ’90s, the safe-sex condom code that we created then has collapsed. And that’s the reality we live in today. Just talking about it, telling people that they’re cowards for not wearing condoms—I don’t think that’s going to create a mass movement of putting condoms on.

Why I am a Truvada Whore: The #TruvadaWhore movement is tongue-in-cheek—most people wearing the shirt are not actual whores—but also, in a sense, literal: we’ve all got a little “whore” in us to the extent that we all belong to the human race.

NYTimes:
Michael Weinstein, president of the AIDS Healthcare Foundation, has called Truvada a “party drug” and argued that the drug regimen would encourage men to avoid condoms and thus increase the infection rate. He called the release of the guidelines “a shameful chapter in the history of the C.D.C.”

SFGate: Truvada generated upward of $3 billion in sales last year. At least 2,300 people were prescribed Truvada for HIV prevention in 2012 and 2013, not including those who use the drug to battle existing HIV infections, Gilead said.
posted by roomthreeseventeen (30 comments total) 8 users marked this as a favorite

 
I got an email that my #truvadawhore t-shirt shipped today.
posted by davidstandaford at 2:43 PM on May 23 [2 favorites]


davidstandaford, thanks for clarifying that the term is not used as a negative, I was looking at the post title with suspicious eyes.
posted by filthy light thief at 2:47 PM on May 23 [1 favorite]


filthy light thief, not at all. See the Why I am a Truvada Whore link.
posted by roomthreeseventeen at 2:48 PM on May 23 [2 favorites]


I think the term was first used as an insult, and is still used as an insult by some, but it has also been reclaimed by many people who are on truvada. I'm curious if anyone knows anything about the origin and first uses of the term.
posted by davidstandaford at 2:50 PM on May 23


I only heard of PrEP when I moved to California. It just wasn't a thing in previous areas I've lived I guess (Montreal + Boston).

Grindr and Scruff out here are full of "I take Truvada and love bareback sex," which is kinda frightening. It may prevent HIV infection, but not other STIs...

That being said, I will probably get a Truvada prescription should my insurance cover it. Better safe than sorry? But I intend to keep wearing condoms too.
posted by Strass at 2:50 PM on May 23


Bah, my reading capabilities today are diminished. My apologies.

And is the cost of "consistent" use less than it was when discussed in the previous thread ($1,2000 per month)?
posted by filthy light thief at 2:51 PM on May 23


Truvada Co-Pay Assistance, but yeah,a cursory internet search has a "street" value of $1306 per month.
posted by roomthreeseventeen at 2:54 PM on May 23


Apparently, I've totally forgotten that # used to be the "pound" sign, because I could not figure out that shirt until I re-read the Out article.
posted by Etrigan at 2:58 PM on May 23 [1 favorite]


The CDC just did a Grand Rounds presentation on PrEP,
CDC Grand Rounds: Pre-Exposure Prophylaxis for Prevention of HIV (1:02:11)
An estimated 50,000 individuals become infected with the human immunodeficiency virus (HIV) in the United States annually. A new prevention strategy, Pre-exposure Prophylaxis (PrEP), is intended for high-risk populations to reduce their risk of becoming infected with HIV. PrEP includes daily medication and routine follow-up. When used consistently, PrEP is shown to reduce the risk of HIV infection. If delivered effectively and used in combination with other proven prevention methods, PrEP may play a significant role in helping to address the HIV epidemic in the United States.
posted by Blasdelb at 2:59 PM on May 23 [3 favorites]


From the CDC link:

Enrollment in the TDF/FTC group was associated with a 44% reduction in the risk of HIV acquisition (95% CI, 15-63).

On average, one's odds of contracting HIV from unprotected sex with strangers is a bit worse than a coin flip, relative to previous risk, unless religiously adhering to the Truvada schedule. Even in the 90% adherence rate cohort, it is only a 77% reduction.

Not nothing, true, but it doesn't seem to be the magic bullet that it is described, if patients don't uniformly adhere to taking it. And that's ignoring other STDs that come along for the ride.

But even if it doesn't do much to reduce HIV rates, it should prove to be blockbuster news for Gilead investors, either way — at least until the insurance companies start increasing the co-pays and patients stop taking it as frequently.
posted by Blazecock Pileon at 4:01 PM on May 23 [2 favorites]


"Only" seems like a weird word to put together with "77% reduction" in the context of discussing a communicable disease. It's huge. Maybe we can not immediately leap to the perfect being the enemy of the good. Unless you've got a secret 100% reduction method that people will faithfully adhere to.
posted by rtha at 4:50 PM on May 23 [2 favorites]


roomthreeseventeen: Truvada Co-Pay Assistance, but yeah,a cursory internet search has a "street" value of $1306 per month.

For that much money, you could literally hire a biologist to follow you around all the time (well, 40 hours a week) and smack you upside the head every time you considered having unprotected sex.
posted by Mitrovarr at 5:10 PM on May 23 [2 favorites]


I dunno.

Based on who I see advertising themselves as on PrEP, and the other high risk activities they frequently claim to engage in, I'm thinking that the 44% number is really more realistic.

This is the part where I can't tell whether I'm just being a scold:

Almost by definition, a lot of high risk sex takes place in circumstances where one or more participants' decision making facilities are hampered by intoxication. In that setting, the value of a super strong taboo against unprotected sex is that those decision making facilities don't get used. If there's a negotiation process, there is going to be many a person who negotiates poorly. And given the price tag associated with the drug at present, I can't help thinking that the public health cost will largely be borne by po folks and melanically enhanced folks. I mean, you're surely not going to be grabbing a pill from the bowl on the bar anytime soon.

I don't know, maybe I'm naive to think there is / ever was such a taboo. Maybe the current prevention methods are failing.

But I do know that throughout all my drunken college hookups (and some were quite drunken) no one ever even suggested not wearing a condom. My understanding is that this is not the experience of women who have sex with men. And I think that's quite a public health accomplishment, and I worry about letting go of it.
posted by PMdixon at 5:15 PM on May 23 [1 favorite]


"77% reduction" is a lot better than several vaccines that are universally recommended and unquestioned.
posted by Slarty Bartfast at 6:19 PM on May 23


Enrollment in the TDF/FTC group was associated with a 44% reduction in the risk of HIV acquisition (95% CI, 15-63).

On average, one's odds of contracting HIV from unprotected sex with strangers is a bit worse than a coin flip, relative to previous risk, unless religiously adhering to the Truvada schedule. Even in the 90% adherence rate cohort, it is only a 77% reduction.

Are you saying that a 44% reduction is "a bit worse than a coin flip, relative to previous risk" or have I completely misunderstood?
posted by ODiV at 6:32 PM on May 23


a "street" value of $1306 per month.
around ~$127/mo from an online pharmacy selling an Indian generic
posted by and they trembled before her fury at 7:21 PM on May 23


What to me is so infuriating--and what so clearly demonstrates the fact that even with health care reform, etc., there are absolutely different standards of care depending on how much money you make--is that apparently insurance companies are not required to cover PrEP Truvada.
posted by cowboy_sally at 7:42 PM on May 23 [1 favorite]


Even if insurance companies are required to cover it, which it sounds like could happen, I think that the people at highest risk for HIV are in demographic groups that are particularly likely to be uninsured. In the US, it seems like our fucked up healthcare system is going to be a barrier to Truvada making a serious dent in the HIV infection rate.

Is it covered by other countries' national healthcare systems?
posted by ArbitraryAndCapricious at 8:04 PM on May 23


In Canada, using Truvada as PrEP is an off-label use. It has not yet been approved for PrEP by Health Canada, but is approved as one of the usual HIV treatment drugs.
posted by heatherann at 8:36 PM on May 23


It's been awhile but I've heard about PrEP in populations where one partner is positive and the other is not specifically for pregnancy. Because there are a vast number of other STIs out there condom user should still be highly recommended.
posted by AlexiaSky at 9:06 PM on May 23


And a bunch of those STIs are becoming more antibiotic resistant by the day! Plus some golden oldies are coming back into style! Looking at you, syphilis!
posted by PMdixon at 10:24 PM on May 23 [3 favorites]


I am indeed a little worried that Truvada could end up being over-trusted. Any doctor that prescribes it without offering a huge disclaimer is being negligent.

That being said, how other people use Truvada is none of my business. As far as HIV prevention goes, Truvada is the closest thing that we have had to a miracle drug.

As a single level of protection, it's not adequate. As an extra layer of redundancy, it's a very, very big improvement.
posted by schmod at 6:32 AM on May 24


That being said, how other people use Truvada is none of my business.

Same goes for antibiotics, yes?
posted by rr at 8:22 AM on May 24


I think the most disturbing thing about the upworthy era of internet news is that you're never quite sure if people are marketing because they believe fervently in the product (I'm definitely guilty of this when it comes to, say, costco) or they've just bought into an advertisement because that they never realized they were being sold something.

I consider truvada an antibiotic in the most literal sense of the word, and like oseltamivir, moxifloxacin, or vancomycin, it's incredibly irresponsible to promote widespread use of these drugs as a lifestyle drug in a fear-based marketing system. I almost suspect that they're trying to cultivate a resistance against tenofovir so we have to start using some of their more expensive, shittier second-line anti-retroviral drugs for HAART. I mean, do you have any idea about how hard it is to get the average middle aged man to take a pill guaranteed to add years to his life on a daily basis, much less at the same time every day? A four dollar, 90 day Wal-Mart prescription of metformin or metoprolol just isn't as sexy, I guess.

Don't want the flu? Get the vaccine, wash your god damn hands. Don't want HIV? Condoms are still your best protection. Yes, they need to be cheaper, or hell, free. Hepatitis C? Work with your city to provide clean needles, disposal in public restrooms, and get cops to stop prosecuting people for paraphernalia. That's the world we live in. Instead the New England Journal of Medicine is advocating some insane six figure treatment for edge cases of viral hepatitis. #america

I am genuinely sorry and have truckloads of empathy for people who get screwed over by the inconvenience and people get fucked over disproportionately. The last time we had this conversation on metafilter I felt like I was being attacked for my views, but it is bad medicine and bad public health policy to advocate the use of this (extremely expensive) drug.

I haven't had a chance to prescribe it as pre-exposure prophylaxis, and I honestly don't know what I would do if someone requested it. I would probably briefly say something about cost and still using safer sex practices and prescribe it anyway. But the pharmaceutical guys have been beating down the doors for a while now on these anti-retrovirals, and these are not harmless drugs. I could provide links but I don't see the point in arguing the science, these corporations do an excellent job of swift boating anybody that comes out against them.

Granted, this is a massive bias on my part as a doctor that goes out of my way to focus on cost-effectiveness and the real harm caused by people paying money they don't have for health care they don't need. We need real public health policy so that health care providers don't have to make highly emotional decisions out of guilt or fear (here's looking at you, the charred, scorched earth left after apocalypse caused by the USPS task force wading into the screening mammography/PSA debate).

Advocating truvada isn't being progressive. This is advertising. And it will only get worse.

This rant is brought to you courtesy of years of suppressed, inchoate rage from trying to get the american healthcare system to help people instead of figuring out novel ways to bill them.

Apologies in advance to the overworked moderators.
posted by hobo gitano de queretaro at 10:22 AM on May 24 [6 favorites]


Medicine is all about balancing risk and benefits, in the case of a patient with known HIV infection and falling CD4 then it's obvious that the benefits of taking Truvada outweigh the risks. Lets not forget that these drugs have significant side-effects and the long-term effects of taking them in non-HIV+ patients just aren't known. They're certainly not sugar pills but they're not a panacea.
posted by zeripath at 10:44 AM on May 24 [1 favorite]


it's incredibly irresponsible to promote widespread use of these drugs as a lifestyle drug in a fear-based marketing system.

That seems to be the era we're stuck with. Many health, beauty, personal hygiene products are advertised using (at least covert) fear tactics. I also see an analogy to widespread (very expensive) surveillance in the era of (vaguely-defined) terrorism.

Creating such fear is an attempt to take advantage of ignorance. And so, It's helpful to be aware of (measured rather than imagined) risks of different kinds of behaviors. (Even then, reliable numbers - for another example, the dangers of second-hand smoke - can be hard to find.)

Reliable information comes from trustworthy sources. Getting reliable information out there, repeatedly, is essential. The unknowns and manipulations that create irrational fears are displaced - giving people the ability to choose, ahead of time, what risk is acceptable.

The medical disease itself is bad enough; the leveraging of fear for profits (and whatever other agendas may be playing out) amounts to another.
posted by Twang at 12:07 PM on May 25 [1 favorite]


The medical disease itself is bad enough; the leveraging of fear for profits

I think this overstates the pure fear component. There is fear marketing, to be sure, but when you see marketing focused on encouraging people to engage in risky (in many ways) behavior, you should ask what benefit they expect.
posted by rr at 12:35 PM on May 25 [1 favorite]


you should ask what benefit they expect

I suspect the pharms expect the same benefit that the alcohol industry and housing industry and credit industry and defense industry expect from promoting risky behavior.

The #1 rule of modern marketing/capitalism seems to be: Profit today, fuck tomorrow. And we're going there as fast as we can.
posted by Twang at 1:11 PM on May 26 [1 favorite]


"Medicine is all about balancing risk and benefits, in the case of a patient with known HIV infection and falling CD4 then it's obvious that the benefits of taking Truvada outweigh the risks. Lets not forget that these drugs have significant side-effects and the long-term effects of taking them in non-HIV+ patients just aren't known. They're certainly not sugar pills but they're not a panacea."
It is important to remember that what is being compared here is not PrEP vs condoms as a means to prevent HIV infection, but the availability of PrEP vs moralizing about condoms as interventions. For at risk populations the cost/benefit analysis becomes a lot easier.
posted by Blasdelb at 7:33 AM on May 28


I agree with you in principle, Blasdelb, but please show me this mythical study population that won't/can't use condoms but will take a very expensive prescription only pill at the same time every day, that will still have problems with reimbursement for probably at least a few years.

Young men in particular, arguably most at risk for contracting HIV where I live, are absolutely terrible at taking cheap, proven daily medications that would likely add years to their lives. But there's no celebrity telethon for high blood pressure.
posted by hobo gitano de queretaro at 12:07 AM on June 3 [1 favorite]


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