Let’s Talk PrEP Workshop Summary

392 smallerThe rise of PrEP as an HIV prevention tool, over the past year has been so dramatic that the acronym seems to need no definition. Pre-exposure prophylaxis, the use of antiviral medication by HIV-negative people to avoid contracting HIV, was approved by the Food and Drug Administration in 2012. Since then federal, state, and local departments of public health and frontline providers have been working to find the best way to learn about it and talk about it.

AHP’s January Let’s Talk PrEP workshop focused differently than many of the information-sharing forums that have concentrated on presenting the facts about PrEP. The workshop began with Kaiser infectious disease specialist Jonathan Volk’s overview on the science of PrEP, which satisfied the need of many workshop attendees for more information about the prevention method. But the workshop primarily sought to provide a safe and engaging space for community members to discuss their thoughts and feelings about PrEP. Most participants agreed that they experienced tremendous stress following slips in their safer sex practices. They were very attracted to a tool to mitigate that anxiety. At the same time, some participants expressed the fear that PrEP is creating divisions within the community, separating those who are “for” it from those who are “against” it. One participant said, “I’m absolutely thrilled to have PrEP as a tool in the toolbox against HIV, but even I get tired of hearing pro-PrEP pep talks.”

Currently Truvada, the brand name for a combination of two drugs, tenofovir disoproxil fumarate and emtricitabine, is the only FDA-approved PrEP formulation. In clinical trials, Truvada reduced the chances of getting HIV by more than 90 percent when it was taken consistently (lower rates of adherence significantly lowered efficacy). The FDA recommends PrEP for people at highest risk of contracting HIV: those who engage in unsafe sex with partners who are HIV-positive or have unknown serostatus, sex workers, and injection drug users.

According to Volk, who worked on the initial clinical trial and has prescribed PrEP for more than 400 patients, Truvada is just the first incarnation of pre-exposure HIV treatment. There are many medication candidates for other forms of PrEP. Clinicians are really interested in creating more than one option that can be safely taken by all genders with minimal side effects. “Truvada is really PrEP 1.0,” Volk said. “Clinical trials are looking at long-lasting PrEP, injectable PrEP, and rectal gels. This is just the beginning.

Currently PrEP has other complications. Cost can be prohibitive, although in the United States, Truvada is available for as little as $25 a month for people with health insurance. Gilead, the maker of Truvada, has an assistance program for those who are uninsured, but in some cases, individuals might have to shoulder a cost of nearly $1,400 a month. One workshop participant worried “that the people who need it the most” for example, sex workers, may be most likely to be uninsured. And in countries outside the United States, cost may be an even more enormous barrier.

“I think of PrEP as being a seasonal medicine,” Volk said to emphasize its episodic and potentially cheaper use. “I don’t imagine that any of my patients will remain on it their entire lives. It’s only necessary in periods of someone’s life where they are engaged in sexual activity that requires PrEP.”

Some of the health professionals at the workshop questioned how to find resources to get PrEP for those who want it but are not covered under insurance. Some health educators voiced apprehension over the information circulating within the community, and expressed the concern that trans folks and women for whom PrEP might be appropriate are not getting messages intended for gay-male target populations. Everyone agreed that the buzz about PrEP seems to mean that more people were talking seriously and honestly about sex. “This is an opportunity to start the conversation,” one participant said, “to take what we learn and continue to talk about it.”