In SF, PrEP Talk Draws A Crowd
More than 100 people packed the Eureka Valley Recreation Center for the latest San Francisco AIDS Foundation Real Talk forum on antiretroviral treatment as prevention and pre-exposure prophylaxis - or PrEP - for HIV.
The forum asked whether being HIV-positive with an undetectable viral load is the "new negative." To make informed decisions about risk today, it is not enough to simply know whether someone is positive or negative - or thinks he is - but also what he is doing in terms of treatment or biomedical prevention.
"We have to think about what it means to have sex today - in 2014, not in 1992," urged moderator David Evans of Project Inform. "I remember those very dark years, but we’re not there anymore. New research has given people more options."
A diverse range of prevention options is more important than ever, according to an unscientific on-the-spot audience phone poll at the May 20 forum. Almost all participants (96 percent) said they had ever had sex without a condom, while 85 percent said they’d had sex with someone of a different HIV status. A majority (60 percent) said they would rather have condomless sex with a person who is HIV-positive with an undetectable viral load, while 19 percent said they would rather do it with someone HIV-negative and 21 percent were not sure.
The latest data continue to show that effective HIV treatment dramatically reduces the risk of sexual transmission. An interim analysis from the Partner Study, reported at the retrovirus conference in March, revealed no cases of HIV transmission among more than 700 serodiscordant couples - including 40 percent same-sex male couples - when the positive partner was on treatment with an undetectable viral load. But the study is still ongoing and seeing no transmissions so far does not mean the risk is zero.
Audience members noted that some HIV-positive men using Grindr and other hook-up apps are now declaring not only that they are positive and on treatment, but even what undetectable viral load threshold they fall under. And some HIV-negative men are stating that they are using PrEP, or taking the antiretroviral combination pill Truvada, to prevent infection.
But some people who regularly take antiretroviral therapy can still be detectable, explained Dr. Joanna Eveland of Mission Neighborhood Health Center. Viral load "blips," or transient increases, are not uncommon, and people may miss drug doses or stop treatment temporarily, for example due to loss of insurance coverage. Someone who thinks he is negative may have recently become infected, a period when viral load is at its highest.
"It should be like [an expiration date] on a milk carton," she suggested. "After a certain date you have to change your status."
Focus on PrEP
While the forum title referred to HIV-positive people on treatment, the focus of discussion quickly turned to PrEP for HIV-negative people. The audience poll revealed that 70 percent of participants were themselves using or knew someone who was using PrEP and 86 percent think it is a viable option to prevent HIV infection.
PrEP has been a major topic of discussion, online and off, after Michael Weinstein of the AIDS Healthcare Foundation recently called Truvada a "party drug’ in an Associated Press interview and pioneering AIDS activist Larry Kramer said that people taking PrEP have "got to have rocks in their heads."
New Centers for Disease Control and Prevention guidelines released earlier this month state that health care providers should consider advising people at "substantial risk" to use PrEP to prevent HIV infection. The Food and Drug Administration approved Gilead Sciences’ Truvada (tenofovir plus emtricitabine) for PrEP in July 2012.
According to the guidelines, PrEP should be considered for people in an ongoing sexual relationship with an HIV-positive partner, gay or bisexual men who have had sex without a condom or been diagnosed with a sexually transmitted infection within the past six months, heterosexual men or women who do not always use condoms when having sex with partners known to be at risk for HIV, and anyone who has recently injected illicit drugs and shared equipment or been in a treatment program for injection drug use.
The guidelines reflect research showing the effectiveness of PrEP for different populations. The iPrEx trial of mostly gay and bisexual men found that taking Truvada once-daily reduced the risk of HIV infection by 42 percent overall, rising to more than 90 percent among participants with blood drug levels indicating regular use.
Panelist David Waggoner said his doctor suggested a few years ago that Truvada PrEP might help him stay negative, after he had requested post-exposure prophylaxis (taking antiretrovirals after sex to prevent infection). While it once sounded daunting to take a daily pill, he has gotten used to it and now takes Truvada with lunch every day. He added that he has never experienced any side effects.