When the acronym PrEP (pre-exposure prophylaxis) and a certain drug by the name of Truvada first got my attention, I was like, “I don’t know what that is, but I don’t like it,” because I pride myself on being open minded.
But seriously, though…it’s a common reaction a lot of folks have to the unknown. There has been a lot of resistance to the idea that a single pill (when taken as directed, people–pay attention) can prevent HIV. There are those who think it’s too good to be true, but some people swear it is the answer to end HIV/AIDS, or at least the future spread of it. There are those who think it’s a conspiracy by the big bad pharmaceutical companies to get everyone hooked on an expensive drug, and of course there are those who equate the pill to a party drug for a bunch of Truvada whores to have sloppy bareback sex, but let’s not get too into that on this here Hiss Fit, shall we?
Whether you believe in it or not, you can’t ignore it. PreP is NOT going away, and the more people resist, the more the topic persists. Whether Truvada is the way to go, or it re-affirms the importance of condom use, there is no denying that education is important. We have options. We can protect ourselves. What option is right for you, totally depends on…well…you. The question is, will you educate yourself and ask questions, or will you decide, “I don’t know what it is, but I don’t like it?”
Below is an article I wrote for the Fight Magazine last month, where I interviewed Eagle Mr. LA Leather 2014 Eric Paul Leue on everything that is PrEP. Space is an issue in print media, so I’m including the transcript in here, because there is no such thing as a dumb question where HIV/AIDS prevention is concerned.
Eric was more than gracious and generous with his time.
This is important, people, so pay attention. And it if you feel like you read it all before, then read it again.
I said, READ!!!
BY PAULO MURILLO
Eagle Mr. LA Leather 2014 and community leader, Eric Paul Leue has worked for HIV awareness and fought against HIV-related stigma and discrimination for over 10 years. In an interview with The Fight, he discusses where we are in the HIV/AIDS crisis, the benefits of prevention through pre-exposure prophylaxis (PrEP), the side effects and side benefits of the PrEP drug Truvada, and the divide between HIV- and HIV+ gay men.
What would you say the rate of new HIV infection is at the moment among men who have sex with men (MSM)?
The Central for Disease Control (CDC) estimates that about two-thirds of all new HIV infections happen in MSM. While in all other population groups the infection rates seem to decrease, statistics show a 12% increase from 2008-2010 in MSM. In the same timeframe infections in young MSM aged 13-24 increased by 22%.
Who are the ones getting infected the most in MSM groups?
The Hispanic community in LA County has the highest number of new HIV infections. However, the African-American community is only 9% of the population, but has 23% of all new HIV infections in MSM (2011). The infection rate pretty much triples the numbers of the Hispanic and White MSM groups.
Where do you think we are as gay men in the dialogue regarding HIV/AIDS and its prevention?
I believe we have arrived at a turning point. As Peter Staley said: “"¦when this crisis is finally over, there will be two kinds of people remembered: those who fought to end it, and those who slowed us down.” Thirty years after the HIV crisis began, we finally have scientific proof that we are able to stop the virus from spreading further with efficacies beyond 99%.
What do you think is missing from that dialogue?
I think it is not so much about what is missing from the dialogue, but what is blocking it and the progress it brings. While sex has become omnipresent–Videogames, TV shows, apps, amateur porn websites with more bareback porn than any studio could ever produce, Rihanna singing about BDSM, et al)–sex is still a huge taboo topic in the US due to primarily religious beliefs. Sex education in schools is suggested, not a must. Our education system basically fails to educate and prepare teenagers, and we can see it in the statistics: HIV infection rates are rising in 13-24-year-olds, teenage pregnancies in the US are four times higher than in Europe, one third of the entire US population has STIs, despite vaccines, HPV and Hepatitis B still make up for 75% of the annual 20 million new STIs in the US; of which 10 million are contracted by young people between 15-24. What we need is a new open mindset, where decisions are fact-based, people are not a dollar amount and different isn't automatically wrong. What may not be right for you, may be right for someone else.
Do you think there is a divide between HIV- and HIV+ men in the gay community that isn't always addressed?
Considering the past 30 years, there are lots of different emotions attached to what was once called "˜gay cancer.' The divide that I see is solely based in heaps of one-sided misinformation as well as cultural and personal judgments over others. I am HIV negative. Two of my three long-term relationships were with HIV positive men. Both basically ended because my partners were afraid of the "˜What if Eric was to become HIV positive through me?' This was not about whether we could or couldn't fuck raw, but because from their perspective the fear of infecting me took the pleasure out of our intimacy. For almost three decades it was ingrained in us that irresponsible, promiscuous bareback sex spreads HIV. It was easy to divide the community into good"”responsible, and bad"”irresponsible. The dawn of new HIV prevention methods like TasP and PrEP adds a whole new spectrum to what it means to be "˜responsible,' "˜safer' and "˜protected.'
You have lead several panels discussing PrEP, what are some of common questions, concerns or talking points that come up in these discussions?
Usually people want to know about how it works and if Truvada is the only form of PrEP, what possible side effects are, what PrEP's efficacy is and why there seem to be so many different numbers, if PrEP replaces condoms and where/ how to get it.
What makes Truvada the drug of choice?
Truvada is the only FDA approved anti-retroviral drug (ARV) combination for PrEP (Pre-Exposure Prophylaxis) since 2012. Other forms of PrEP such as long-term injections, gels & rings, as well as other drugs such as maraviroc and ripilvirine are currently being researched. Truvada was first FDA approved in 2004 for use as anti-retroviral treatment (ART). It is the most prescribed HIV treatment medication, shows the least side effects, consists of only one pill per day and consists of two active agents (tenofovir, TDF and emtricitabine, FTC).
Exactly what does Truvada do to your body?
Truvada's active agents TDF and FTC are so called nucleoside reverse transcriptase inhibitors. In order for HIV to successfully infect a person, it needs to reproduce. There are different enzymes we know of that the virus needs to do that. Truvada prevents the virus from reproducing by blocking one of the enzymes. The CDC guidelines about PrEP tell us that 7 consecutive doses are needed before this ‘block’ is effective in anal tissue, and 20 consecutive doses are needed to do the same in cervicovaginal tissue.
The IPERGAY study in France/Canada is evaluating the efficacies of an intermittent PrEP use of two doses within 24-2hrs before sex, and one dose each at 24 and 48hrs afterwards. While first findings look promising I am going to wait for the final results. The first released data shows that the median number of anal sex was 2 per week. While they could both happen in one day (don’t smirk, it has happened to me too 🙂 …), they could also be spread out like for example on Tuesday and Friday which would basically be the same as daily doses.
What are the side effects?
There are side effects and side benefits. Most people I have talked to experience what we call the starter syndrome. Those mild side effects like nausea, diarrhea, night sweats, etc. usually occur within the first four weeks and disappear. Other side effects that show over time are usually bone density loss, and effects on liver and kidneys. While none of the side effects are irreversible after the prevention regime is discontinued, they also don't appear as often in HIV- people as in HIV+ people. People are always concerned about toxicity levels and like to get polemic by comparing Truvada to the first ever ART called AZT. AZT has a toxicity switch ratio of 43.5%. TDF is at 6.4% and FTC at even less with 1.2%. The regular check-ups are what I call a side benefit. One of the most valuable side benefits though, is the alleviation of anxiety about HIV.
How important is a daily dosage as directed?
"˜As directed' does not just mean daily, but daily at about the same time of day. This is important for two reasons: efficacy and adherence. A daily routine is generally easier to adhere to than if I do something every other day and the 2014 CDC guidelines about PrEP state that with 7 doses per week an HIV transmission prevention efficacy of 92% is achieved.
What happens if you miss a dosage or two?
First of all, only you know what works for you. Truvada is very different from condoms when looking at how adherence affects efficacy. Taking PrEP is for example, part of the morning routine right after brushing your teeth. Condoms are used right in the moment before the anal or vaginal fuckery commences. So the question you need to ask yourself is "˜Am I more likely to adhere to a pill in the morning, or putting on a condom in the moment of sex?' Condoms are 70% efficacious in preventing HIV, but only for the 16.4% of the MSM who always use them during anal intercourse. For the "˜small' number of 83.6% of the MSM that do not always use them, the efficacy of condoms is basically 0%. PrEP is different, because even if I miss a dose, PrEP's half-life is between 31hrs (TDF) and 37hrs (FTC), meaning the drug levels only slowly decrease. A regression model calculation based on the iPrex study showed in 2012 that PrEP's efficacy is 99% with 7 pills per week, 96% with 4 pills per week and 76% with 2 pills per week. In the iPrex Open Label Extension (OLE) the researchers found that no patients that adhered to more than 4 doses per week were infected with HIV.
Where does PrEP fit in with other STIs?
Counter question: where do contraceptives fit in with STIs, or where do condoms fit in with oral, skin-to-skin, or smear-infections?
PrEP (in form of Truvada) prevents HIV infections in the entire body of an HIV negative person and it reduces the chance of getting infected with herpes. While Truvada (specifically tenofovir) is also used as treatment for Hepatitis B, it does not prevent any other STIs. One of the biggest challenges regarding the conversation about PrEP is the misconception that STIs are only contracted through vaginal/anal intercourse and hence a condom stops every infection.
There are bacterial STIs like gonorrhea, chlamydia and syphilis, and viral STIs like HIV, herpes, HPV and hepatitis B. All of these bacteria / viral infections can be transmitted through other ways than just condomless anal/vaginal intercourse. Most of them even through oral sex, "intense" kissing, or even as a smear infection from a toilet seat or door handle.
I have personally had chlamydia & gonorrhea in my throat, and I have had a cold sore on my lips once or twice, which would mean that I have herpes just like pretty much everybody else in the U.S. does. Scary? No, but I suppose if you don't know what that means, it could be.
First of all, I mentioned this before, regular testing–knowing of an infection–is key in preventing transmissions by enabling us to stop the transmissions cycle. In the U.S. only half of all people between 18-44 have at least had one HIV/STI test in their life. That's a very low number. PrEP users will at least have four tests per year and hence inspire others to do the same by making regular testing normal.
Secondly, let's put it in perspective, in numbers. HIV is often referred to as the only STI that can't be cured. While there are other incurable infections like HSV (herpes), specific types of hepatitis, and HPV (human papillomavirus), untreated HIV remains to be the most fatal.
The iPrex OLE study"”as well as every other study"”found that there was "no sign of increased risk behavior among PrEP users." Realistically I believe there will be some people who choose to abandon condoms once they are on PrEP, but I also know that there are people that chose not to use condoms before PrEP came around. In either case we wouldn't abandon contraceptives for not preventing STIs, nor would we abandon condoms for not preventing oral, skin-to-skin, or smear-infections. I don't think it is wise to oppose PrEP on the same grounds on which we would have to abandon every other prevention tool too. PrEP prevents the most dangerous of the common STIs with the highest efficacy.
Do you think judgments against big pharmaceutical companies affect the way gay men approach Truvada?
When I first heard of PrEP, I wasn't sure what to think of it because I felt like gay men were being turned in cash cows by selling them what sounded almost too good to be true. Looking at the cost of Truvada long-term, it is less costly to have people on PrEP than to pay for lifelong treatment and other costs associated with an HIV infection. Yes, gay men are careful, we don't like being taken advantage of. Though PrEP really has proven itself as the best HIV transmission prevention we have. I will happily join a conversation about the cost of Truvada and work on reducing the price, increasing assistance payments of working on better terms with insurance companies.
SF AIDS Foundation tweeted that the re-appropriation of #TruvadaWhore may have unintended impact of stigmatizing HIV negative people who do not use PrEP, do you believe this is true?
I saw the tweet and am not sure how that would come into play. I have actually not heard anything about that from HIV negative people who do not use PrEP. The way that I look at Adam Zeboski's #TruvadaWhore campaign is that it is a play on words. Someone wanted to insult responsible HIV negative guys who are making use of the best HIV transmission prevention we have, and Adam turned its meaning around and now uses it proudly to advocate. I find it similar to when we use words like, "˜faggot', "˜princess', "˜queen', "˜tranny', etc. I don't think that any of these words are being used within the LGBT community to upset our hurt our own. We use them and laugh at ourselves, showing the world that we celebrate us in full frontal honesty.
In one of your panels I attended, there was mention of a 19-year old boy who contracted HIV from his 18-year old boyfriend, how would a 19-year old get his hands on Truvada?
I am sorry to hear that. Before going into greater depth with the answer here, if the 19 year old knew that he was possibly exposed, he could have also made use of PEP (Post-Exposure Prophylaxis) within 72 hours. In both cases I would refer him to LA LGBT Center. Their staff is specifically trained to discuss accessing PrEP and providing PEP. For PrEP it usually depends on his insurance status, available assistance programs, or he might even be suitable for one of the study sites here in LA County. The LA County HIV Commission also just assigned $1-1.5 million towards PrEP & PEP, so I am sure we will see change in the accessibility of both in the near future.
Some people say the price of Truvada separates the gay community into two classes, the rich who can afford it, and the poor who should stick to condoms; do you believe this to be true?
Just looking at California and that Medicaid covers the full cost of PrEP without any additional costs, no I don't think that we are dividing the gay community into different social classes. Private insurances may require copays or a high deductible, but I believe this will be a temporary issue for those that are considering PrEP as an option.
What are some testimonials on PrEP that stand out in your mind?
Quite honestly the one I hear the most is by the generation that had to experience the first years of HIV: "˜If we had had this 30 years ago we would have all been on it. We would have demonstrated, broken down gates and doors to get it cheaper, make it more accessible, and to protect everybody.'
What are some resources you can recommend where gay men can educate themselves on PrEP?
We are working on a website specifically for LA County right now where providers, educators and organizations will be listed, UCLA, LA LGBT Center, APLA and Walls Las Memorias would be the first four organizations that I would recommend to get in touch with if you want someone in person to talk to. Alta Med, the Children's Hospital, Being Alive LA, REACH LA, the Oasis Clinic at MLK and Doctors like Tony Mills are all great resources too. Online, I would recommend PrEP Facts group on FB by Damon L. Jacobs; facebook.com/groups groups/PrEPFacts, #TruvadaWhore group on FB by Adam Z, facebook.com/groups/LoadsToTalkAbout, aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pre-exposure-prophylaxis/, start.truvada.com/#, myprepexperience.blogspot.com/, and prepfacts.org/ Eric Paul Leue can be reached via Facebook at Mr LA Leather.