San Francisco Goes All-In on HIV Pill

San Francisco Supervisor Scott Wiener has become the first politician in the United States to disclose that he’s taking Truvada as PrEP, a once-daily pill to prevent HIV.

Meanwhile, his colleague on the city's board of supervisors, David Campos, wants to make PrEP available to everyone in San Francisco regardless of their ability to pay. He will introduce a resolution Tuesday urging expanded city support for its PrEP program

PrEP stands for pre-exposure prophylaxis. Truvada as PrEP costs about $1,200 per month and is covered by many private insurers and state Medicaid programs, including California’s.

A pill to prevent HIV is something many people at risk for the disease, including gay men like the 44-year-old Wiener, have dreamed about for decades.

Now that PrEP is here, uptake has been slow. While public health officials and HIV prevention specialists have overwhelmingly embraced it, PrEP still has fierce detractors. Some doctors and many people in at-risk communities fear it will breed resistant strains of HIV and discourage condom use.

Some opponents have been openly hostile, even referring to people who take PrEP as “whores.”

“Had this come into existence in the late 1980s there would have been lines around the corner to obtain it,” Wiener told Healthline. “It would have been the top public health strategy around HIV prevention. It would have been a universally embraced prevention method. Fast forward a few decades and we have people who are disparaging it and trying to shame people from using it. That’s really unfortunate.”

Wiener represents the same San Francisco district as iconic gay rights pioneer Harvey Milk, who was assassinated by a colleague on the board of supervisors in 1978.

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The Truth About PrEP and Condom Use

In the HIV prevention community, San Francisco is considered a model for its success in combatting the HIV and AIDS epidemic. Last year, the city of San Francisco saw 360 new HIV infections, Wiener said. That number has been declining slowly for several years.

New infections persist, however, particularly among men who have sex with men. HIV prevention specialists readily admit that “condom fatigue” is rampant in the gay and bisexual community. A 2012 study showed that just one in three anal sex acts among men were condom protected. Advocates welcome PrEP as another prevention tool in the arsenal.

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Condoms do fail, and are more likely to do so during anal sex, the U.S. Food and Drug Administration (FDA) warns. PrEP is up to 92 percent effective at preventing HIV infections when taken as directed, according to the U.S. Centers for Disease Control and Prevention (CDC).

Scientific studies have shown that most people taking PrEP do not begin to practice unsafe sex as a result. But many gay men say the dangerous lure of PrEP is that it allows men to forego condoms.

Public health is about meeting people where they are, not about trying to shame people to get them to be where you want them to be.
San Francisco Supervisor Scott Wiener

“Smart public health is about trying to use all preventions, and not about trying to shame people into changing behavior that we’ve not been able to change for 30 years because people are who we are,” Wiener said. “Public health is about meeting people where they are, not about trying to shame people to get them to be where you want them to be.”

When the FDA approved Truvada as PrEP in 2012, the agency said the drug should be used in conjunction with other safe sex practices.

LGBT People Still Make Up Most New Infections

Among the 50,000 new cases of HIV diagnosed every year in the United States, 63 percent are among men who have sex with men, according to the CDC. While the overall number of infections has remained relatively stable over the past several years, infections rates among young black men who have sex with men rose 20 percent between 2008 and 2010.

Many people in at-risk groups do not know they have HIV and do not get tested. Stigma surrounding HIV prevents many people from discussing risky behaviors or getting tested. Some marginalized groups, such as transgender people, have such trouble accessing healthcare that HIV testing and treatment is out of reach. The CDC says transgender people are among those most at risk for HIV.

Amaya Perez-Brumer is a Columbia University sociologist using a government grant to study PrEP adherence in transgender populations. Transgender people are so heavily stigmatized in medical settings, even in big cities, that they often avoid them. Perez-Brumer has heard many reports of people snickering in doctor's office waiting rooms and even of doctors refusing to treat transgender patients.

She sees an added benefit of PrEP for transgender people at risk of HIV. “In my opinion, one of the greatest benefits about PrEP is that it forces routine clinical care,” she said, noting that PrEP prescription guidelines recommend quarterly checkups with a doctor.

As of September 2013, just 2,319 people had filled prescriptions for Truvada as PrEP, according to its manufacturer, Gilead Sciences. About half of those were women.

Women can’t always insist that their male partners use condoms. Education about PrEP ... will enable healthcare providers to offer PrEP to women looking for another HIV prevention option — one that they can control.
Anna Forbes, U.S. Women and PrEP Working Group

The Positive Women’s Network-USA (PWN-USA) applauded the CDC when it endorsed the use of PrEP as an HIV prevention method. “Women can’t always insist that their male partners use condoms,” said Anna Forbes of the U.S. Women and PReP Working Group in a PWN-USA press release. “Education about PrEP and this CDC guidance will enable healthcare providers to offer PrEP to women looking for another HIV prevention option — one that they can control. That’s a step forward for women.”

Gilead's statistics don’t paint a complete picture of the current PrEP environment. They don’t include the thousands of gay and bisexual men and transgender women who have taken PrEP in clinical trials. Their data is drawn from about half of the nation’s retail pharmacies.

In May, the CDC called for all at-risk groups to consider taking PrEP for HIV prevention. Later, the World Health Organization did the same.

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Public Health Departments Step Up Prevention Efforts

Wiener said a variety of models could be used to fund his colleague’s proposal for universal PReP access in San Francisco.

Even with private insurance coverage and Medicaid coverage in many states, the $1,200 per month cost of Truvada remains prohibitive for people who must share the brunt of the cost. More and more public health departments are stepping up to make the drug available.

The state of Washington has created PrEP DAP, a program to help people pay for PrEP. New York City has also launched an aggressive campaign to help at-risk groups obtain PrEP.

Wiener is up for re-election in November. Damon Jacobs, who runs a Facebook page where people can interact with others taking PrEP or learn more about it, applauds Wiener for speaking out about taking PrEP, particularly during an election cycle.

“The level of integrity he is demonstrating is admirable and inspiring in a way that would make Harvey Milk proud,” Jacobs told Healthline.

Photo of Scott Wiener courtesy of One Laptop Per Child/Flickr

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