The first of a two-part series about PrEP's relevance to African American men who have sex with men.
In what has been described as a "major breakthrough," the daily use of an antiretroviral drug by HIV-negative gay and bisexual men has been proved to dramatically reduce new HIV infections.
The results of the clinical trials involving Truvada lend hope to the new prevention technology known as pre-exposure prophylaxis (pdf), or PrEP. The initial study results were announced in November 2010. Updated data were presented during February at the Conference on Retroviruses and Opportunistic Infections and at a daylong meeting organized by the Centers for Disease Control and Prevention (CDC). Both meetings took place in Boston.
The number one question on everyone's mind at the conferences: How do you move PrEP from the pages of scientific journals to a viable, easily accessible option?
"And how do you implement it for the number one risk group for HIV/AIDS: African American men who have sex with men?" asks Detroit-based Hank Milbourne, director of prevention services at AIDS Partnership Michigan.
The study -- read an abstract here -- found that men taking Gilead Sciences' Truvada were 43.8 percent less likely to become infected than those taking a placebo. The data revealed even higher levels of protection from HIV infection, up to 73 percent, among participants who adhered most closely to the daily drug regimen.
PrEP opens a new line of attack in HIV prevention, especially among those who may not be wearing condoms "because they sell sex, are in danger of prison rape, are under pressure from partners or lose their inhibitions when drunk or high," reports The New York Times.
Jim Pickett, director of advocacy for the AIDS Foundation of Chicago, attended the CDC's Boston meeting and agrees. "Condoms are fantastic and extremely effective. But we need choices for people who can't or won't use them for whatever reason. If you are not using condoms, you deserve a choice that is better than nothing."
"The study results show that PrEP can be a very important prevention tool," says Jirair Ratevosian, M.P.H., deputy director of policy at the Foundation for AIDS Research (amfAR), who also attended the Boston conferences. "But we also understand that PrEP is not for everyone," he adds.
The study included nearly 2,500 participants, mostly men who engage in high-risk sex with other men, and was conducted in six countries: Brazil, Ecuador, Peru, South Africa, Thailand and the United States.
And there lies the "challenge," say some Black HIV-prevention specialists who are expert in MSM (men who have sex with men). "Only about 10 percent of the participants were residents of the United States," notes Milbourne. "A smaller percentage was African American. I have questions if there were cultural variances in treatment adherence, accessibility and taking medications."
AIDS Partnership Michigan serves up to 10,000 clients per year who are seeking HIV-prevention services in the Detroit area, which Milbourne describes as the "epicenter" of the epidemic in Michigan. "Black MSM are the predominant group affected by HIV here, and ... implementing PrEP to the community would be a challenge," he says. "It's more than taking a pill. It's a matter of consistent monitoring of a person's HIV status. "And most of our clients don't have that access to medical care," Milbourne adds.
A recent CDC study of more than 8,100 MSM found that almost one in three Black men who have sex with men is HIV positive, compared with only 16 percent of White gay and bisexual men. Black poz MSM were least likely to be aware of their status -- 59 percent unaware versus 26 percent for White MSM. The numbers for younger Black MSM are even more startling, with 71 percent unaware of their infection.
Ratevosian of amFAR suggests that Black gay and bisexual men could benefit from PrEP: "We know that the Black and Latino population's access to health care and HIV/AIDS preventive services on by the Black and Latino population is pathetic. The National HIV/AIDS Strategy (pdf) prioritizes Black MSM because they are most vulnerable. At the same time, extremely few prevention approaches are working for these populations, so PrEP gives us reason to be hopeful."
But first, "more demonstration projects are needed" to test and measure the effectiveness of the interventions, Ratevosian says. "We have to focus on vulnerable groups: MSM, young gay Black and Latino communities, women of color."
"PrEP is an intervention that has a number of moving parts that all need to be working for it to be safe and effective," says Chicago's Pickett. "We need seat belts and air bags on our cars to protect us from harm when we are driving. Take any of them away and you are more likely to get hurt. Adding PrEP to our prevention toolbox helps to ensure that fewer people get hurt. "
Milbourne estimates that about "one in every five Black MSM in Michigan" is HIV positive. He views PrEP as part of a "comprehensive" HIV-prevention package for Black MSM. "It's certainly not a first line of defense or offense in prevention," he says. "It's too expensive. And most African American MSM do not have insurance or the type of insurance that would pay for it. "
Indeed, the major question is who will pay for the drug. In the United States, Truvada can cost $36 a day or up to $14,000 a year, reports NPR.
"Questions around cost and access are concerns to everyone," Pickett says. "We don't just want this to be a 'boutique' intervention available only to the privileged few."
Rod McCullom has written and produced for ABC News and NBC, and his reporting and analysis have appeared in Ebony, The Advocate, ColorLines and other media.