Truvada for HIV prevention

[nymanhole]

Thanks for the info!!!

[rawTOP]

Also, be aware that just last month, most insurance companies will NO LONGER cover Truvada for anyone who is not already poz.

My plan just renewed my prescription for Truvada/PrEP, but it looks like some insurance companies (and Medicaid plans) are pushing back on PrEP - see details at this link… http://myprepexperience.blogspot.com/p/truvada-track.html

[wood]

My plan just renewed my prescription for Truvada/PrEP, but it looks like some insurance companies (and Medicaid plans) are pushing back on PrEP - see details at this link… http://myprepexperience.blogspot.com/p/truvada-track.html

For those who are worried about the cost of PrEP or other drugs for that matter, The indian drug company Cipla makes a generic of Truvada called Tenvir-em. you can find it at any number of online pharmacies for about $100 a month. (note: I have never used the company listed below)

http://www.inhousepharmacy.biz/p-636-tenvir-em.aspx

Now normally I would say that an off market drug source of something that is supposed to have no generic formulation would be stupid, but Cipla is actually very respected, and they are actually the worlds largest manufacturer of HIV/AIDS medication. The wikipedia article explains wit well, but basically India until recently didnt allow patents on drugs, so they pretty much make what they want. I have used their "Tadacip" aka Tadalafil, or Cialis, and it works just as well as the pricey stuff for a fraction of the cost.

http://en.wikipedia.org/wiki/Cipla

I have used this online drugstore and it was actually reccomended by my doctor, it is NOT a fly by night operation, and you actually need a doctor to fax in your script, but they are very trustworthy.

http://www.universaldrugstore.com/

[PhoenixGeoff]

My plan just renewed my prescription for Truvada/PrEP, but it looks like some insurance companies (and Medicaid plans) are pushing back on PrEP - see details at this link… http://myprepexperience.blogspot.com/p/truvada-track.html

This article might be apropos.

From Sean Strub’s calculations (in his comment to my post on the POZ magazine website) which included doctor’s visits and tests, the annual cost [of PrEP with Truvada] would be about $500.000.

Implementation of PrEP on a wide scale will almost certainly result in an increase in new infections. It’s not only adherence to the drug regimen that will not be maintained by all. Adherence to a schedule of regular testing for infection cannot be relied on.

The way PrEP has been promoted has probably already damaged targeted prevention education programs with support for continued condom use, an activity already in great need of support.

Setting aside the issue of compliance (and I'd imagine that guys on PrEP would feel considerably more free to take treatment "holidays"), this guy does have a point. If going on PrEP gives guys a false sense of security and lets them think that they're free to start barebacking like, well, I do without fear of HIV, you're going to get more cases of HIV, not less. 2.3% of the guys in the study on PrEP still were infected.

Now remember the Russian Roulette analogy I've made in the past. Yes, it's great that your odds of infection are cut in half. But if you then end up going out and getting bred by a hundred or so guys as a result, where previously you would have been either using condoms (which rather than cutting your risk in half, lowers it by at least an order of magnitude) or wouldn't have been so promiscuous (remembering that every time you have sex, you raise your cumulative risk of infection, because HIV only has to "get lucky" once), then you're actually worse off than you were before and the insurance company is out a metric shit-ton of cash.

PrEP might make sense for men like us, who are going to bareback anyways. The problem is, what does it do for those guys looking at us enviously who don't have the balls (or the insanity, depending on your point of view) to cast caution to the wind like we do.

I've got a feeling that PrEP is largely going to turn out to be a dead end, except in a pretty small number of cases.

And I also think that encouraging guys to bareback because PrEP is a silver bullet is irresponsible. My own advice will remain the same, PrEP or no PrEP: if you're even slightly worried about HIV, you shouldn't bareback.

[wood]

This article might be apropos.

Setting aside the issue of compliance (and I'd imagine that guys on PrEP would feel considerably more free to take treatment "holidays"), this guy does have a point. If going on PrEP gives guys a false sense of security and lets them think that they're free to start barebacking like, well, I do without fear of HIV, you're going to get more cases of HIV, not less. 2.3% of the guys in the study on PrEP still were infected.

Now remember the Russian Roulette analogy I've made in the past. Yes, it's great that your odds of infection are cut in half. But if you then end up going out and getting bred by a hundred or so guys as a result, where previously you would have been either using condoms (which rather than cutting your risk in half, lowers it by at least an order of magnitude) or wouldn't have been so promiscuous (remembering that every time you have sex, you raise your cumulative risk of infection, because HIV only has to "get lucky" once), then you're actually worse off than you were before and the insurance company is out a metric shit-ton of cash.

PrEP might make sense for men like us, who are going to bareback anyways. The problem is, what does it do for those guys looking at us enviously who don't have the balls (or the insanity, depending on your point of view) to cast caution to the wind like we do.

I've got a feeling that PrEP is largely going to turn out to be a dead end, except in a pretty small number of cases.

And I also think that encouraging guys to bareback because PrEP is a silver bullet is irresponsible. My own advice will remain the same, PrEP or no PrEP: if you're even slightly worried about HIV, you shouldn't bareback.

masmountainman, you make some really good points in regards to PrEP, and I fully respect your opinion on the matter. That being said, that "article" is terrible in every way from how it is written to the "facts" they are trying to prove. they are simply playing with statistics to make it look like it doesnt work. What they are trying to do is say (falsely) is that it "only reduces your risk 2.8% and it costs 500k a year.

The fact still stands that PrEP only reduces risk, it does not eliminate it. So if you are the guy out there getting bred by anyone all the time, you almost certainly will end up poz, PrEP or not. However, if you have a lower constant risk level, IE in a relationship, or something along those lines, it is an effective tool to help prevent infection.

"Surprisingly, we found that the iPrEx participants didn't have to adhere perfectly to the drug regimen to reap Truvada's benefits," said Dr. Grant. "Even in those patients who didn't adhere perfectly, their risk of contracting HIV still dropped by more than 90% -- offering a high level of protection against the virus."

from http://www.thebodypro.com/content/69650/truvadas-efficacy-as-prep-reaffirmed.html

Heres article explaining the effectiveness of PrEP and how effectiveness dropped when it wasnt taken correctly.

http://www.sciencedaily.com/releases/2012/09/120913105005.htm

Heres the long and short of it.

1) PrEP still has to be taken correctly to convey full effectiveness, and even at that it is not 100%

2) People who participate in extremely risky behavior or increase their level of risky behavior will likely still become poz.

3) There can be major side effects to PrEP.

4) Taken correctly it can offer a significant reduction in the chance of contracting HIV.

The fact that PrEP works should not really be a surprise to anyone. People who go on PEP for exposure have a significant reduction in the chance of infection, and PrEP is in effect doing the same thing in advance. IMO, far from going away, I think that until there is a cure, or vaccine we will see increased PrEP options, and possibly tailor made PrEP options, with lower doses of medication, but possibly more medication combos.

[Guest JizzDumpWI]

TI've got a feeling that PrEP is largely going to turn out to be a dead end, except in a pretty small number of cases.

And I also think that encouraging guys to bareback because PrEP is a silver bullet is irresponsible. My own advice will remain the same, PrEP or no PrEP: if you're even slightly worried about HIV, you shouldn't bareback.

Whether or not PrEP turns out to be a dead end is not something I care to speculate about. Else I might play the ponies (so to speak).

I think as you know, I've always only barebacked. But I do like what I think may be the added benefit of reducing risk of contracting HIV. That isn't to imply that I am "worried". Just that given the choice, it would be better to not contract HIV than not.

I am on PrEP, well for just a couple of weeks now. Not sure how it will affect me. First labs in another couple of weeks. And to be honest, I am more concerned about what they might show up than I ever was for HIV. Any inkling of issues and I'll be stopping...

BUT, aside from that, it is nice to take raw loads with the same lack of concern that you do mascmountainman. So if PrEP doesn't result with me being hit with nasty side effects, I'll stay on. If I do have nasty side effects; stop; and contract HIV (which I suspect is unlikely anyway given that I've only barebacked since the late 70's, and remain neg); at least there is one drug regimen we know of that I probably won't tolerate.

I am, I acknowledge, trusting that the first labs will be informative.

[fskn]

MascMountainMan, as hollywoodslut pointed out, there are big problems with the article you linked to.

First and foremost, the overall results of the iPrEx study (64 infections among 1,248 placebo users versus 36 HIV infections among 1,251 Truvada users, for a 44% reduction) reflect less-than-perfect adherence.

http://www.niaid.nih.gov/news/QA/Pages/iPrExQA.aspx

Truvada was highly effective for people who took it regularly. "[A]t least one of the study-drug components was detected in 3 of 34 subjects with HIV infection (9%)..." In other words, almost all of the people who became infected were not taking Truvada! Among participants who had detectable levels of Truvada's components in their blood, there was "a relative reduction in HIV risk of 92%."

http://www.nejm.org/doi/full/10.1056/NEJMoa1011205#t=articleResults

The authors of the article you linked are flat-out wrong about Truvada's "relatively low efficacy." Other online commentators retracted similar statements when they read the iPrEX results in detail and remembered that no drug works if you don't take it.

I can't speak for other people, but I take my medicine religiously, because it could save my life. I wouldn't want my access to this drug to be compromised because other patients do not, or for whatever reason are not able to, comply with the drug regimen.

Whether PrEP goes to high-risk patients and whether they take it regularly will determine its actual societal benefit. It's far too early to speculate about who will have access to PrEP, who will choose it, and who will use it regularly. The number of PrEP patients in the U.S. today is probably just in the hundreds. Even though clinical trials are finished, the practical use of Truvada for PrEP in the field is still being studied (see especially the DEMO Project in San Francisco).

On the cost side, drug prices decline over time and with greater usage, as do the costs of diagnostic tests (like the rapid HIV test, used in all up-to-date healthcare facilities and particularly important for PrEP patients).

The authors of the article have some nerve to complain about the cost of frequent HIV testing ("...does not even include the cost of the necessary monitoring for infection...it was suggested that such monitoring be done monthly to prevent the emergence of resistant virus by detecting infection early"). Getting more men to test more often will, in and of itself, reduce unintentional transmission of HIV.

Even when we do know real-world adherence rates, and when the cost of the drug settles at a normal, post-patent level, the concept of dollars per year per infection prevented will remain abstract. If I'm talking about my own life, or the life of someone I care about, any price is worth it.

Edited August 20, 2013 by fskn

[PhoenixGeoff]

OK, I'll accept that there may be problems with the article I linked to. However, there are some indisputable facts:

1) Truvada's patent doesn't expire in the US until 2021. Between now and then, we're talking astronomical prices, about $900 per month or $10,800 per year retail.

2) Even when generic medications come out, many HIV meds are very complicated to synthesize and the market for them is relatively small. Which means we almost certainly won't be seeing $5 generic Truvada. Hollywoodslut found an Indian generic that costs $100 per month. $1200 per year is still a lot of money for most people.

3) Adherence is absolutely an issue. So, for that reason, is drug resistance. It's entirely possible that we could end up with widespread drug resistant HIV thanks to PrEP, just as we're seeing with gonorrhea right now.

I think it's incumbent on PrEP advocates to show that adherence to PrEP is a problem that can be overcome. Research shows that "Only 6% of the patients took >=95% of their medications, the optimal level for durable virologic and clinical success.".

Think about that: 94% people with an incurable, deadly disease, who have been advised of the risks of nonadherence, nevertheless still fail to take their medications in such a way that will prevent resistance and keep them alive.

What do you think the adherence rate will be for people who aren't HIV+? Do you think they might find it easier to say "Fuck it" when push comes to shove?

I'm telling you, as someone who's been there, adherence over the long term is not easy. Life situations come up. You forget your meds at home when you go on vacation. Or you have to work late. Or you get drunk. Or whatever...shit happens.

4) "If I'm talking about my own life, or the life of someone I care about, any price is worth it."

This just makes absolutely no economic sense. Like it or not, resources are limited. We're having massive battles over health care in the US right now precisely because not everyone is willing to pay any price to cover everybody's health care.

And you need to face facts: unless you're independently wealthy, you are asking people who aren't you, who frankly don't care about you, don't even know you, to subsidize your health care.

And I can prove it thus: as I said, retail cost of Truvada is about $900 per month. Let's call it $10,000 per year. Median income in the US for men over 25 is around $40,000 before taxes. Would you be willing to dedicate one quarter of everything you earn to PrEP? By way of comparison, $900/month will get you a pretty decent one bedroom apartment in Denver. How many people would be willing to pay that for PrEP? What would you have to forego in order to make that payment?

Now, apply that decision on a national scale. Thankfully, through Ryan White and other government programs, those of us who are HIV+ have our own choices very heavily subsidized, so we don't have to make that kind of life-or-death decision. But we shouldn't confuse that heavy subsidy for an infinite capacity to underwrite any and all medical expenses.

And the point I made still stands: if people are going to be at least as promiscuous (if not more so) and if PrEP is going to only be partially effective (whether for reasons of adherence or whatever), in short, if they are going to get HIV anyway, does it make sense now to spend the extra money on PrEP?

My guess is that the answer the actuaries will come back with will be "no".

[rawTOP]

MascMountainMan - I generally agree with what you just said except in one respect…

3) Adherence is absolutely an issue. So, for that reason, is drug resistance. It's entirely possible that we could end up with widespread drug resistant HIV thanks to PrEP, just as we're seeing with gonorrhea right now.

That's what I used to think, but it's not true. Because it's the HIV in your body that becomes resistant, neg guys can't become resistant to ARVs. Hence PrEP is unlikely to result in "widespread drug resistant HIV". Except in one respect - a some but not all of guys on PrEP who convert do become resistant, but that happens after they become poz, not before. So it will happen, but it won't be widespread.

[PhoenixGeoff]

MascMountainMan - I generally agree with what you just said except in one respect…

That's what I used to think, but it's not true. Because it's the HIV in your body that becomes resistant, neg guys can't become resistant to ARVs. Hence PrEP is unlikely to result in "widespread drug resistant HIV". Except in one respect - a some but not all of guys on PrEP who convert do become resistant, but that happens after they become poz, not before. So it will happen, but it won't be widespread.

Right, but what's the next step? Those guys don't stop barebacking once they become positive; quite the contrary. And now, instead of spreading wild type HIV, they're spreading Truvada resistant HIV, including to guys who have the wild type form of the virus.

[rawTOP]

Right, but what's the next step? Those guys don't stop barebacking once they become positive; quite the contrary. And now, instead of spreading wild type HIV, they're spreading Truvada resistant HIV, including to guys who have the wild type form of the virus.

The key is for doctors to tell guys on PrEP to come in quickly when they have possible seroconversion symtoms. If they go off Truvada quickly there won't be resistance.

[Guest JizzDumpWI]

And in my case that is my docs instruction...

BTW just because your HIV is resistant to Truvada in you doesn't mean it will be in me, should I contract HIV from you. The virus combined with the different immune system will or won't result in the newly infected ones resistence.

Cost: If Truvada costs 900 per month, that is still less than the 2,000 per month post infection.

[kinkygradstudent]

The key is for doctors to tell guys on PrEP to come in quickly when they have possible seroconversion symtoms. If they go off Truvada quickly there won't be resistance.

Or add another medication or two to the Truvada, alternatively.

Actually, the studies showed almost no resistance developing even when people seroconverted. That's part of why they chose Truvada for PrEP, because it wasn't producing resistance like they had possibly feared. I think they found like one person in the study who developed a resistant strain, and upon further examination they had been hiv-positive when they started PrEP, but had been in the window period and weren't testing poz yet when they started the Truvada. Hence it being important to confirm the negative before you start PrEP, and to not bareback in the window period before your initial RNA test.

[wood]

I think that one thing people are missing here is that truvada for PrEP was fully approved by the FDA for that usage. That alone is not an easy task to achieve. The system isnt perfect, but the drug approval process, and even approving an existing drug for a different use is quite complicated, and the burden of proof is always on the drug maker. If it doesn't work, and isn't safe to do so it doesn't get approved. A perfect example is adderall's ussage as a diet aid. A doctor could in theory perscribe it for diet purposes but it is not approved for that simply because there was way too many issues from addiction to heart problems that can result from its use.

Truvada for PrEP isnt perfect, but it is an effective way to help control the spread of HIV. This is not a magic pill that will eliminate risk, but another tool to reduce it.

[Bottom Jim]

My two cents. There is only one totally effective way to avoid infection. Never have any kind of sex anymore . Since most would say that is not an option then the treatment helps. I do it but of course am still careful about who fucks me