Wednesday, July 18, 2018

Would more American use PrEP if it were less expensive, or are there other reasons gay white men in urban areas seem to be the only ones on-board?

Interesting op-ed by three venerable AIDS activists. But HIV writer Ben Ryan sounds he is on to something here ...

Ben Ryan
July 16 at 9:59 PM
While I applaud Peter Staley and James Krellenstein for fighting the good fight in an effort to lower the wholesale acquisition cost of Truvada for its use as PrEP, I remain unconvinced that Truvada’s WAC is a primary, or in fact even a major, impediment to PrEP uptake in the United States. I could certainly be convinced, but I have yet to see any solid evidence, ideally in the form of a published study or other major report, supporting this claim. I remain unconvinced that if a generic did exist that it would: a) cost dramatically less in the United States than Truvada does today; and b) would result in less cost sharing for consumers, especially if the generic drug did not have its own copay assistance program as Truvada does through Gilead (people could very well go from no copay at all to having a copay each month).
According to my own numerous conversations with researchers and public health advocates, and in my reading of studies about PrEP uptake, the major factors impeding PrEP access, at least on an individual level, include but are not limited to: medical disenfranchisement and lack of insurance; lack of awareness of PrEP; lack of comprehension of one’s high risk status; fear of being stigmatized for using PrEP; a lack of willingness to see the doctor quarterly for a PrEP prescription; fear of side effects; actual side effects; medical mistrust; a lack of ability to adhere to a daily drug; a belief, often false, that PrEP is financially out of reach; a lack of ability to find a PrEP-friendly physician; and so on.
I am also continually frustrated by those within the HIV community—this includes the CDC and prominent researchers—who use a simplistic numerator and denominator to come to the conclusion that PrEP use is woefully low: simply take the total number of PrEP users and divide it by the 1.2 million PrEP candidates per the CDC’s estimates. But virtually all PrEP users are men who have sex with men (MSM), so one should in fact divide the number of PrEP users by the number of MSM the CDC considers good PrEP candidates. And one should consider that in certain communities, including Seattle, San Francisco and New York City, PrEP use is actually incredibly high; the drug is already pushing down HIV rates in those communities according to multiple public health experts. PrEP should not be considered only on a national scale; it’s important to look at the local phenomena of its use.
Six years into the PrEP era, as use of Truvada for prevention continues to soar, I find myself scratching my head over the persistence of the same head-scratching headlines that we saw in 2013—“Why aren’t people using PrEP?” The real question at this point is much more nuanced: “Why is PrEP only used by white MSM over 25 in major urban areas outside of the South?” Finding the answer to that question is much more complicated than simply trying to lower the cost of the drug.
I do encourage the effort to lower the cost of Truvada and to break the patent. But the HIV community would be remiss if it got seduced by a narrative that promised instant results from success at this feat. The continued effort to promote PrEP requires a much more nuanced and multifaceted campaign.
And at the end of the day, if PrEP is not a good fit for certain parts of the at-risk population, then the HIV advocacy and research community must continue searching for answers about how to lower HIV incidence among such groups instead of simply falling prey to the very American presumption that it can all be solved with a pill.