Will Truvada help young black gay men avoid HIV?
A clinic in the historically African-American neighborhood of Baldwin Hills has launched a program to give patients easier access to Truvada, a once-a-day pill shown to drastically reduce the risk of contracting HIV.
Doctors and staff at the Gleicher/Chen Health Center, run by the nonprofit AIDS Project Los Angeles, say the drug known as Truvada could become a key part of the effort to reduce new HIV infections among young black gay and bisexual men, who have the county’s highest rate of new infections.
Vallerie Wagner, the clinic’s chief operating officer, said it considers the drug "an important tool in the overall HIV prevention tool kit."
But despite its proven effectiveness at preventing the transmission of HIV, the drug has not been universally embraced. Indeed, since it was approved by the FDA as a preventive pill more than two years ago, Truvada has been slow to catch on among doctors and patients. Some advocates are concerned that the drug could actually put users at greater risk, because they might use it incorrectly or because it could encourage more unprotected sex.
The clinic has rolled its program out in a way meant to address these concerns, though its doctors say they recognize the challenges they’ll face in ensuring their patients use the pill safely.
Truvada works by maintaining a reservoir of the drug in the body so that someone who is exposed to HIV can quickly fight it off before it establishes itself in the system. The strategy is known as pre-exposure prophylaxis, or PrEP, and has been shown to be more than 90 percent effective.
But the concerns stem from the fact that taking the pill daily is seen as critical, at the same time that it is intended for people at high risk for HIV, many of whom may be less likely to adhere to the strict regimen.
Young black gay men, for example, have the highest rate of HIV. About one-third of black gay men in L.A. County are estimated to have the virus. They are also at highest risk for infection, and yet are least likely to get tested for the virus, or to get into or remain in treatment after contracting it.
That reality raises serious questions as to whether many of these men will adhere to Truvada’s daily regimen, said Greg Wilson, who provides support to young black gay men at the nonprofit Reach L.A. Many of his clients have troubled backgrounds and are low income, and some are homeless.
"Going from that, to saying, 'OK, now starting today every single day at the same time if possible, you take this one pill?' And expect them to not mess up? That’s a level of responsibility that they have not ever had to deal with," Wilson said.
This is compounded by the fact that some of his clients on Truvada have said they’re less likely to use condoms. Wilson said they’ve been lulled into a false sense of security because they see the pill as a magic bullet as opposed to a backup plan. He wants Truvada to come with lots of education about its safe use.
These concerns have also led the Los Angeles-based AIDS Healthcare Foundation, the nation’s largest HIV treatment provider, to oppose Truvada.
"The CDC indications say you should use Truvada with condoms, but in real life that's not what's happening," said Michael Weinstein, the foundation's president.
This lack of knowledge about Truvada is something that Dr. Christian Nakayama, the APLA clinic’s HIV specialist, has seen himself.
"Most people will come in saying something along the lines of, I heard there’s a pill I can take to not get HIV," Takayama said. "Well, yes. But it’s not that simple."
He said that when a patient asks for the pill, he explains that Truvada is a commitment, and ideally should be used in conjunction with condoms. It must be taken daily. Missing doses makes preventing HIV transmission much less likely. And to make matters worse, if someone on the drug ends up contracting HIV and continues taking Truvada, the virus can become resistant and harder to treat. Because of that, the clinic requires patients to come in for regular HIV tests.
Takayama said that after learning these facts, "most people back off."
For those who decide they do want the drug, the clinic’s program is designed to guide patients through its use in a way that most private doctors do not. It will include case managers who will follow up with patients to ensure they’re taking the drug safely and to schedule follow-up visits for HIV tests, which become opportunities for doctors to check for side effects.
At more than $1,000 a month, Truvada is not cheap. But it is covered by most private health plans and Medi-Cal, the state Medicaid program, allowing the clinic to make it available to its mostly low-income patients. (Though most of those who've requested the pill are African-American men, it is available to anyone).
But Dr. Gifty Ntim, the clinic’s medical director, said those who miss multiple appointments or who fail to take their daily dose will be required to sign a contract acknowledging the requirements. If they continue slipping up, they’ll be denied the drug.
"Because we want to do it in a safe way, we want to do it in a responsible way," Ntim said.
They want it to be used by people like 20-year-old Frankie James, whose grandfather and cousin both died of AIDS, and who himself is at greater risk for contracting HIV because he is young, black and gay.
James takes the pill every day.
"It makes me feel a little bit secure in my sexual life," he said. "It kind of eliminates a little bit of fear, because along with my condoms I also have this extra backup plan."