There's an almost-perfect HIV prevention pill, but not enough people are using it
One-third of primary care doctors have never heard of the pill, according to a report released by the US Centers for Disease Control and Prevention on Tuesday.
The CDC says that Truvada, a prophylactic that protects against HIV, should be offered to people at high risk, including about one in four gay and bisexual men, one in five injecting drug users, and one in 200 sexually active heterosexual adults. But not nearly enough people are taking the pill, which is also called PrEP.
Today, 1.2 million Americans are living with HIV, and despite years of work to end transmission, the virus is still spreading. Yet fewer than 2,000 people filled prescriptions for Truvada in the first years after its approval.
"PrEP isn't reaching many people who could benefit from it, and many providers remain unaware of its promise," CDC Director Dr. Tom Frieden said in the press release about the report. "With about 40,000 HIV infections newly diagnosed each year in the U.S., we need to use all available prevention strategies."
'100% effective'
Back in 2010, the clinical trial that led to the drug's 2012 approval found that Truvada was 99% effective at protecting gay men from the virus. (It had already been approved years earlier as a treatment for people who were HIV positive.) , it's "been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%."
But there's a catch. In order to achieve these incredible protection rates, you have to take it every day. And humans are not very good at doing that. That's a critical issue if people take the drug imperfectly but proceed as if they're safe. It's "much less effective," the CDC notes, "if it is not taken consistently."
A study published this September in Clinical Infectious Diseases followed 657 patients who took Truvada for almost three years. The participants were HIV-negative, but at high risk of contracting the virus. Yet during the course of the study, none of them did.
Some publications have hailed the drug as "100% effective." It's important to note, however, that the September study was not a clinical trial; there was not a control group that did not take the drug, so it's impossible to say how many more cases there would have been in a non-Truvada group. Still, the results were encouraging.
"PrEP has the potential to dramatically reduce new HIV infections in the nation," Dr. Jonathan Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, said in the press release on Tuesday. "However, PrEP only works if patients know about it, have access to it, and take it as prescribed."
Overcoming stigma
Part of the reason why Truvada hasn't been widely adopted is because there is serious stigma associated with taking it. Opponents of the drug argue that taking it will embolden people to engage in unsafe sexual practices, like foregoing condoms. The phrase "Truvada Whore" has become a pejorative way of referring to people who choose to take the drug to protect themselves from HIV/AIDS.
But numerous studies have shown that taking the drug doesn't actually result in ditching safe sex practices.
"The problem," Mark Joseph Stern writes for Slate, "lies in a generational dispute between older gay men, who lived through the worst of the AIDS crisis, and younger ones, who often see HIV as little more than a chronic but manageable disease."
In a great feature story in Out magazine by Tim Murphy, an anonymous doctor explained why he kept the fact that he takes Truvada a secret:
He ... doesn't want to be judged for eschewing condoms from time to time. "Gay men talking about not using condoms is really stigmatized," he says. "Most of us have never known sex without condoms or without threat of a 'deadly disease.' " But he adds passionately, "I think it's a lot to ask an entire generation of gay men to use condoms forever."
Of course, the pill only prevents against HIV, so people taking it can still get other STDs like hepatitis and chlamydia. Condom use and frequent testing is still recommended for people taking Truvada.
The drug has some potentially serious side effects, but the most common ones are minor, like diarrhea, nausea, and headache. Most insurance companies cover it, and federal guidelines put into place in 2014 recommend drugs like Truvada for people at high-risk of contracting HIV.
Truvada could potentially prevent people from ever contracting HIV - if only more people took it, and remembered to take it every day.