Context and the Blue Pill of Prevention

Did you read Tim Murphy's article in the July 14-27 New York Magazine called, "Forgetting HIV?" It's one of many stories that have appeared in the last few months trying to contextualize PrEP (pre-exposure prophylaxis -- a drug called Truvada, the blue pill). These stories offering a white, affluent, gay, male-centric perspective have hit the street running. The term "Truvada whore" is already an early soundbite from mainstream media. But don't be fooled. The first voices may be the loudest, but they are not the most important in the bigger picture of the epidemic. Let's make sure the poor, the underserved and the hard to reach are front and center of this conversation.

So let's give it some context of our own -- some public health context.

Who is PrEP supposed to be for?

PrEP is recommended for the following populations at high risk of acquiring HIV infection -- what we'll call "the big six": 1) MSM, 2) injection drug users, 3) Sero-discordant couples, 4) Transgenders. 5) Sex workers and 6) Individuals with a history of STI's within the last year (i.e.: people having unprotected sexual intercourse).

Who are MSM?

The abbreviation MSM (Men who have sex with men) is getting used a lot these days along with YMSM (Young MSM) in the media, in the lecture hall and in the community. It's a term that emerged from epidemiological studies on HIV describing who you have sex with and doesn't take into consideration sexual orientation. MSM are men partnering with men whether they identify as gay, bisexual or straight. MSM are not just self-identifying gay men. African American (13-24 years old) YMSM are an especially high risk group, with new infections rising significantly each year while other group rates are leveling off or decreasing. Note that no-one calls themselves an MSM and that many MSM identify as straight.

What puts an MSM at substantial risk of acquiring HIV infection? Let's go to the clinical guidelines: 1) Having an HIV-positive sexual partner; 2) Having a recent bacterial sexually transmitted infection (signifying unprotected sex); 3) Having a high number of sex partners; 4) Having a history of inconsistent or no condom use or 5) Engaging in commercial sex work.

What if you're heterosexual?

Can you be offered PrEP if you're straight? The answer is yes. Let's not forget that half of the adult cases of HIV worldwide are women and that women of color have been hit especially hard. What puts you at substantial risk of acquiring HIV infection and therefore makes you a candidate for the blue pill? 1) Having an HIV-positive sexual partner; 2) Having had a recent bacterial sexually transmitted infection; 3) Having had a high number of sex partners; 4) Having a history of inconsistent or no condom use; 5) Engaging in commercial sex work and 6) Living in a high-prevalence area or network.

Can you see the pattern here?

What about transgender people?

Transgender women sex worker infection rates are through the roof. Transgender people are also statistically more likely to be discriminated against by healthcare workers, not get their healthcare needs met and stay out of the unfriendly -- but Truvada prescribing -- healthcare system.

How is it going to work?

We have a waterfall metaphor in the HIV Treatment Cascade of Care. We start with 100 percent of the 1.1 million people with HIV and end up with 25 percent virally suppressed by HIV medications. The current is strong. Of all the people who have HIV in the U.S. about 82 percent have been tested. Of these we drop down to 66 percent linked to care. Then we drop again down to 37 percent retained in care, 33 percent prescribed HIV medications, and about 25 percent actually virally suppressed. The way to end the epidemic is to collect, place into care, retain, treat, and adhere. Make the waterfall a gentle river or a still lake.

We will have a similar cascade for PrEP, but no one's talking about it yet. We have to be aware of it so that we can address its challenges. It's a cascade of treatment to prevent getting an illness - its treatment for the well. We know from our experiences with HIV medications for people living with HIV that adherence is not as simple as giving people a pill and expecting them to take it every day.

The PrEP Cascade?

We don't have numbers yet -- researchers let's catch up -- but look at its components. In the PrEP cascade we'll start with how many people fall into the big six high risk categories for risk of getting HIV. Of those at high risk how many know they are at risk? Of those who know they're at risk, how many are in regular care with a doctor? Of those in regular care, how many will either know about and ask for PrEP or be asked by a clinician who has accurately assessed their risk? Of those, how many will say yes to preventive treatment? Of those who say yes, how many will remain adherent to the daily regimen for 30 days, 60 days, 90 days, or longer?

What are the odds - if you're a transgender woman, sex worker, young African American MSM (who identifies as straight), woman in an unknown sero-discordant relationship with a man, bisexual male, or an active injection drug user - of making it through this PrEP cascade to adherence? I think most of them won't make it to the doctor's office.

These are individuals who don't access regular care, are discriminated against, tend to distrust the healthcare system, and don't connect themselves to the AIDS epidemic either personally or publicly. They will need outreach to connect them to care. They will need education to help them see the need for care. They will need skills to help them with adherence. They need to be the larger and better context for the dialogue on PrEP because Truvada whore is a great catch-phrase but not representative of the bigger picture. And the one thing this epidemic doesn't need is to sideline a bigger picture prevention tool with potential before its implementation has even begun.