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Crosscurrents

PrEP: Could a once-a-day pill end the HIV epidemic in San Francisco?

Daniel Moore
Mural portrait of Esteban Cuaya-Muñoz at the Oakland Museum of California, by artist Brett Cooke"

For decades, San Francisco has been offering free condoms, STD testing, and counseling to its residents to help end the HIV epidemic. These interventions have had a big impact over the years, but the city still saw about 350 new HIV infections last year.  And nationally, “there are about 50,000 new HIV infections that happen ever year,” according to Susan Philip of the San Francisco Department of Public Health. “That is an unacceptable number. So we know that we need more tools in the arsenal.”

Philip thinks something called PrEP is just that, a powerful new tool in the arsenal. PrEP, which stands for pre-exposure prophylaxis, is a new way to prevent HIV infections using a drug called Truvada. Truvada has been used for over a decade to treat HIV but since 2012, the drug has been approved for a new purpose: HIV prevention. Taken daily, Truvada has been shown to be over 90% effective at reducing the risk of HIV infection.  

In November, San Francisco’s Board of Supervisors approved legislation allocating $300,000 to help San Franciscans who want PrEP to get access to it.  While many people haven’t even heard of it, PrEP is already changing lives and the calculus by which gay men make decisions about their sexual health.

Being on PrEP

Andre San-Chez is a 26-year-old gay man who lives in the East Bay. He is vocal about being on PrEP, and says PrEP has changed his sex life.

“I used to be known as the condom queen, because I was always preaching that you need to have safe sex, you need to have protected sex, you need to be informed, so talk to your partners. PrEP has let me be a little more liberal.”

San-Chez identifies as African American and Latino. As a man of color, he has a particularly high risk of contracting HIV. In fact, in 2010, the HIV infection rate for African Americans was almost eight times that of their white counterparts. So he’s participating in a research study that makes PrEP available, for free, to men of color like himself.

San-Chez says he still talks with his partners about their HIV status and asks when they last got tested, but being on PrEP helps him feel like he has an added layer of protection. 

“Because there is the ‘what if’ -- what if the condom breaks, what if I get drunk at a party and decide to have sex but there is no other form of protection around,” he says.

Men like San-Chez who have multiple male sex partners aren’t the only ones benefiting from PrEP. Monogamous couples are using it too. Anthony Lucas is HIV-positive. His partner Esteban Cuaya-Muñoz is negative, and on PrEP. 

“For a really long time I started to think that condomless sex is this privilege that only heterosexual couples got to have," says Lucas. "And I felt kind robbed of that. I kind of felt like I was a monster because I was positive.”

Lucas says PrEP has changed not just their sex life but the intimacy between them: “I can't imagine my sex life, or emotional or spiritual life, anything other than what it is right now as a result of this one minor thing -- which is I know I am not going to infect him.”

Access and Usage

But it’s not just gay men. PrEP can work for other people at risk for HIV -- like sex workers, IV drug users, or anyone with an HIV-positive partner.  All told, the Center for Disease Control estimates that over 400,000 people in the United States would benefit from PrEP, yet very few people are being treated.  

“When you look at PrEP and the potential that it has, I think it's really surprising that only a few people have had access to it,” says San Francisco Supervisor David Campos, co-author of the recent PrEP legislation.

He believes that cost is one of the biggest hurdles to improving access to PrEP. Without insurance, Truvada, the medication used for PrEP, is expensive. It costs about $1,200 a month, or over $14,000 a year. Most insurance companies will pay for PrEP, but not all of it. That means some patients are stuck with unaffordable co-pays and deductibles. 

Supervisor Campos sees the drug’s manufacturer, Gilead, as part of the problem. Gilead sells Truvada, the medication used for PrEP, to low-income countries for a fraction of the U.S. price, less than $30 a month.

“We're still in conversations with them, but I would hope that more could be done by the manufacturer to help people [in the U.S.],” says Campos.

But even at its full cost of $14,000 a year, the price tag for PrEP may be worth it, according to Susan Philip from the San Francisco Department of Public Health: “PrEP is a relatively expensive intervention, but living with HIV is also an expensive proposition.”

In fact, the estimated cost of treating one HIV infection over a lifetime can be more than $500,000.

“There's also the human costs,” notes Philip. “You have to think about the life years affected ... These are often relatively young people, healthy, who then go on to have to manage a chronic disease for the rest of their life.”

For those who take their medications regularly, the drug is extremely effective, according to Dr. Robert Grant, a leading researcher on PrEP.

“Based on our statistical analysis what we're saying now is that the protective benefit is over 96%," says Grant. "In fact, no one has gotten infected who is taking the pill four or more times a week.”

For comparison, consistent condom use among gay men reduces the risk of HIV infection by only 70%. According to Dr. Grant, PrEP has real advantages over traditional prophylaxis.

“PrEP really is taken anytime during the day. And typically people take it in a calm moment during the day and it gives them an opportunity to think calmly about what they want from their sexual lives and how they are going to avoid HIV.”

Benefits, Risks, and Unknowns

Beyond preventing HIV transmission, PrEP can have surprising effects on people too.

“It actually made me think more about my health,” explains HIV-negative Esteban Cuaya-Muñoz. “In fact, right now, one of the benefits for me is knowing that I’m taking care of myself. It's also eating healthy. I've also stopped drinking alcohol.”

Cuaya-Muñoz’s partner Lucas agrees.

“I feel like ever since you started PrEP you took extra good care of yourself. You get tested regularly, and you eat differently.”

For Lucas and Cuaya-Muñoz, the benefits of PrEP are clear. And so are the risk factors. Lucas knows his status, is proactive about his health, and wants to protect his partner. But for many other sexually active people, there are a lot more unknowns.  

One medical student on PrEP who wished to remain anonymous put it like this: “I am at risk, [but] I can't quite quantify, which I would have loved to when I was deciding to go on PrEP. I would have loved to have a solid number, like a formula that I could plug in: what are my exposures, how many partners do I have, what types of sex I have with the partners?”

That formula doesn’t exist, but for many, PrEP is a powerful option in the fight against HIV and AIDS. And yet few people are on it. So after more than 30 years, the end of the epidemic may still be out of reach.  

 

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Crosscurrents HIV/AIDS