CDC Endorses Truvada For HIV Prevention Purposes

There was important news in the fight against HIV/AIDS this week. The federal government announced they were issuing guidelines that recommend that sexually active HIV-negative gay men take doses of Truvada for "pre-exposure prophylaxis" (PrEP) purposes.

The guidelines say PrEP should be considered for HIV-uninfected patients with any of the following indications:

• Anyone who is in an ongoing sexual relationship with an HIV-infected partner.

• A gay or bisexual man who has had sex without a condom or has been diagnosed with a sexually transmitted infection within the past six months, and is not in a mutually monogamous relationship with a partner who recently tested HIV-negative.

• A heterosexual man or woman who does not always use condoms when having sex with partners known to be at risk for HIV (for example, injecting drug users or bisexual male partners of unknown HIV status), and is not in a mutually-monogamous relationship with a partner who recently tested HIV-negative.

• Anyone who has, within the past six months, injected illicit drugs and shared equipment or been in a treatment program for injection drug use.

“While a vaccine or cure may one day end the HIV epidemic, PrEP is a powerful tool that has the potential to alter the course of the U.S. HIV epidemic today,” said Jonathan Mermin, M.D., M.P.H., director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “These guidelines represent an important step toward fully realizing the promise of PrEP. We should add to this momentum, working to ensure that PrEP is used by the right people, in the right way, in the right circumstances.”

This is a very important step. California's largest AIDS service providers had endorsed this position a few weeks ago, so it is good that this policy position will adopted nationwide.

CA AIDS Service Organizations Applaud Easier Access To Truvada For HIV Prevention With HIV-Negative Gay Men

For Immediate Release
Friday, April 18, 2014

Phil Curtis
213.201.1623
pcurtis@apla.org

Gil Diaz
323-993-7604
gdiaz@lagaycenter.org

Anne Donnelly
415.558.8669x208
adonnelly@projectinform.org

California Improves Access to HIV Prevention Pill
Important new tool in fighting AIDS, Pre-exposure prophylaxis (PrEP)
may be up to 99% effective in preventing new infections

Three leading California AIDS organizations -- AIDS Project Los Angeles, the L.A. Gay & Lesbian Center and Project Inform in San Francisco -- today applauded California’s Medi-Cal program for easing access to a well-established AIDS medication that has been proven to prevent HIV infection in at risk individuals.

The action lifts a requirement that doctors complete an authorization request when prescribing PrEP for HIV negative individuals.  PrEP is the brand drug Truvada, an AIDS drug manufactured by Gilead Sciences in Foster City, CA.  The action is effective immediately and will be published in Medi-Cal’s June Provider Bulletin.

Many in the HIV/AIDS community consider PrEP a groundbreaking HIV prevention tool.  The authorization request is considered an obstacle for both doctors and patients. With Medi-Cal’s action, doctors will now be able to prescribe the drug for men and women who test HIV negative and indicate that they are “at risk” of infection through HIV exposure.

“The Medi-Cal ruling is a game changer in HIV prevention,” said AIDS Project Los Angeles Executive Director Craig E. Thompson. “Appropriate access to PrEP through Medi-Cal provides us with another intervention – along with safer sex and condom use – to reduce the number of new HIV infections.”

“Medi-Cal’s action also brings an element of health equity to the program’s low-income beneficiaries,” Thompson said. “Private insurance plans have been covering PrEP for some time, often without prior authorization.”

"Project Inform and other organizations working directly with people at risk of acquiring HIV have conjectured that the slow uptake of PrEP may be more attributable to clinicians' reluctance to provide sexual health services of this type than to patients' lack of knowledge of PrEP or willingness to take it,” said Project Inform’s Executive Director Dana Van Gorder. “Lifting the TAR removes a potential obstacle that may have contributed to providers’ reluctance to prescribe PrEP."

Research modeling shows Truvada may be up to 99 percent effective in preventing new infections, depending on adherence and whether the drug is used in conjunction with safer sex counseling, provision of condoms and other prevention services.

“By making it easier for people at-risk of HIV infection to get access to medicine that has been proven to prevent HIV infection, California has set an important precedent for the rest of the nation,” said L.A. Gay & Lesbian Center Chief of Staff Darrel Cummings. “This collaboration between Medi-Cal and community advocates will move California closer to the comprehensive response that is needed to help end the HIV epidemic.”

The policy change resulted from discussions with Medi-Cal’s Pharmacy Policy Branch Chief, Mike Wofford, his staff and representatives from APLA, the L.A. Gay & Lesbian Center and Project Inform. The discussions focused on provider knowledge of PrEP, possible side effects associated with long-term use of Truvada, and community acceptance of the intervention.

Previously, Medi-Cal patients asking for Truvada could have been asked to meet several conditions outlined in the TAR for “high risk” individuals. Some of these conditions could have required the provision of condoms and monthly HIV testing – not necessarily real world conditions.

“There is a reason the AIDS community is talking about ending the epidemic,” Thompson said.  “We have three successful medical interventions to reduce new infections, including PrEP. What we need now is broad community and provider education on these interventions to increase acceptance and utilization.”

The three interventions include: PrEP for at risk HIV negative individuals, post-exposure prophylaxis or PEP for people who know or suspect they have been exposed to HIV, and HIV anti-retroviral treatment as prevention (TasP) for those living with HIV (HIV/AIDS drugs can bring viral load -- the amount of virus in the body -- down to undetectable levels in people who are HIV positive, reducing the likelihood that they will be able to transmit the virus to sexual partners).

# # #

NYT Spotlights HIV Crisis Among Young Black and Latino Men Under 25

Well, this is a surprise! Today the New York Times has a front page, above the fold (most prominent placement), story entitled "Poor Black and Hispanic Men Are the Face of H.I.V." by Donald G. McNeil Jr. The key point is that 25 percent of new infections are in men who are either Black or Latino.

Here's an excerpt:

Nationally, 25 percent of new infections are in black and Hispanic men, and in New York City it is 45 percent, according to the Centers for Disease Control and Prevention and the city’s health department. 

Nationally, when only men under 25 infected through gay sex are counted, 80 percent are black or Hispanic — even though they engage in less high-risk behavior than their white peers. 

The prospects for change look grim. Critics say little is being done to save this group, and none of it with any great urgency. 

“There wasn’t even an ad campaign aimed at young black men until last year — what’s that about?” said Krishna Stone, a spokeswoman for GMHC, which was founded in the 1980s as the Gay Men’s Health Crisis. 

Phill Wilson, president of the Black AIDS Institute in Los Angeles, said there were “no models out there right now for reaching these men.” 

[...] 

According to a major C.D.C.-led study, a male-male sex act for a young black American is eight times as likely to end in H.I.V. infection as it is for his white peers. 

That is true even though, on average, black youths in the study took fewer risks than their white peers: they had fewer partners, engaged in fewer acts of sex while drunk or high, and used condoms more often. 

They had other risk factors. Lacking health insurance, they were less likely to have seen doctors regularly and more likely to have syphilis, which creates a path for H.I.V. 

But the crucial factor was that more of their partners were older black men, who are much more likely to have untreated H.I.V. than older white men.

The fact that the HIV epidemic is becoming browner and younger has been known by HIV activists for quite awhile but it is useful that the mainstream media is starting to pay attention and send the message to the wider population.

I'm somewhat surprised that my friend Phill Wilson is quoted saying there are "no models" for reaching young Black and Latino men who have sex with men (MSM), when he runs the Black AIDS Institute which is a national organization focused on creating, studying and promulgating such models.

In Los Angeles, In The Meantime Men is an organization which focuses on HIV prevention in young Black men and Bienestar focuses on HIV prevention and treatment in the Latino community.

I think what Phill meant to say was that there are no widely adopted or generally accepted models for reaching the communities the article is focused on.

Shame! Gov. Brown Vetoes Bll Allowing Condoms In Prison

There is bad news to report today on the status of the progressive goal to improve the lives and health of people in locked facilities in California.

Governor Jerry Brown has finally completed his work on the 900+ bills the Democratic super majority in the California legislature sent him this session. He has taken some action that progressives applaud and some that we can only shake our head at and wonder "What was he thinking?"

Overall, the Governor vetoed 96 bills in total and signed into law 805.

However, some of his more controversial legislative actions took place at the end, which occurred this weekend. On Saturday October 12th, Governor Brown vetoed AB 999 (Prisoner Protections for Family and Community Health Act) which would have eventually allowed condoms in state prisons. The Governor's Office released his veto message:

To The Members of the California State Assembly: 

I am returning Assembly Member Bill 999 without my signature. 

This bill would require the California Department of Corrections and Rehabilitation to develop a plan to expand the availability of condoms to all California prisons. 

The Department currently allows family visitors to bring condoms for the purpose of the family overnight visitation program. While expansion of this program may be warranted, the Department should evaluate and implement this expansion carefully and within its existing authority.  

Sincerely 

Edmund G. Brown, Jr

This is disappointing news. As readers of the blog may know, I have been on the board of directors of the Center for Health Justice for years. Health Justice has the mission to eliminate disparities between prisoner health and public health and one way it does this is by distribution of condoms in Los Angeles County jails.

The point of the legislation was to give CDCR the authority (and political cover) to consider the availability of condoms in prisons (we're talking about a condom machine, people). This is because people in prison have sex with each other, and people who are in prison often have sexually transmitted infections. Officially, sex between prisoners is against the law, so making condoms available is viewed by some as an enticement to break the law. Most public health advocates strongly support actions that will "reduce harm" and they agree that increased access to condoms in locked facilities will improve the health of prisoners (and the public) and will not reduce safety for those who work in locked facilities.

It is unfortunate Gov. Brown had to use AB 999 as an example to show less progressive members of the political spectrum his conservative bona fides. He now joins his predecessor, Republican Governor Arnold Schwarzenegger in vetoing a measure that would have allowed condoms in prison.

Shame on you, Governor!

Campaign To Test 1 Million Angelenos for HIV Announced

Despite the announcement happening on one of my own local public radio stations on the Friday before World AIDS Day, I somehow missed the news story that Mayor Antonio Villaraigosa intends to launch a campaign to test 1 million residents of Los Angeles for HIV. Here's a transcript of the reporter by KPCC reporter Brian Watt:

Nurse: What I'm gonna do is swab your gum line on the top and also on the bottom. Okay, so if you can open up.

Brian Watt: In a matter of seconds, a nurse from the non-profit AltaMed health center gave Mayor Antonio Villaraigosa a rapid swab HIV test. The results come back within 20 minutes. By the end of the program in the parking lot of the Ramona Gardens housing project, Villaraigosa could stand under an umbrella and share his results.

Mayor Antonio Villaraigosa: I'm negative, but what's important is not whether people are negative or positive. What's important is that you take the test.

Watt: L.A. City Council members Jan Perry and Jose Huizar, and Congresswoman Linda Sanchez joined Villaraigosa in an effort to beat back the stigma and fear associated with HIV testing. They cited statistics showing that HIV is on the rise among blacks, Latinos, and Asians.

But the statistic driving this citywide initiative to test a million people is this: A quarter of Angelenos who are HIV positive don't know it.

Dr. Felix Carpillo: And that's why the infection continues to grow, because that pool of individuals are having sex and they don't know that they are passing the disease.

Watt: Dr. Felix Carpillo directs HIV services for AltaMed.

Carpillo: We know that once they know their status, patients tend to really, you know, behave better, and by understanding, they can just protect their partners.

Watt: But the challenge, says Carpillo, is getting people to take the test and find out. He says many are stuck in the past. They think only certain kinds of people get the virus that causes AIDS. And that AIDS is a lethal disease that kills quickly, as it appeared to in the 1980s. But Carpillo says that's changed. Anyone can get AIDS, but it doesn't mean they're gonna die a fast death.

Carpillo: We have options in treatment that can help the patients live a very productive and long life, as much as they were going to live anyway, if they take the medications.

Watt: The initiative in Los Angeles will expand HIV testing at more than 50 hospitals and clinics. The money to do that comes from the AIDS Healthcare Foundation, Gilead Sciences, and OraSure, which makes the rapid swab test.

How could this possibly be cost-effective? If each HIV test costs $20 then this campaign will cost at least $20 million, but since at most .5% of the general population you are spending $20 million to identify at most 5,000 HIV+ Los Angeles residents, or a cost of $4,000 per person. This is why most experts say that targeted HIV testing campaigns are more effective and provide more bang for the buck.