Will You PrEP?

Science has always been a realm that fascinated and captivated me. It’s the sole reason why I am pursing the major and degree that I am, as well as being a consistent employee of the pharmaceutical industry for a decade now. Science continues to produce some of the most ground-breaking breakthroughs, in our time. Take CRISPR for example. Additionally, which is what I would like to expand on moving forward, PrEP, or Pre-exposure prophylaxis.

Briefly, PrEP is a combination of two HIV medicines (tenofovir and emtricitabine), sold under the name Truvada®. Quite simply, daily PrEP use can lower the risk of getting HIV from sex by more than 90% and from injection drug use by more than 70%. It was first approved on July 16, 2012, yet despite being on the market for a little over six years now, many individuals aren’t taking advantage of the preventative pharmaceutical wonder.

You would think it would be as simple as talking to a physician and getting your prescription. However the reality is, there are many individuals across the globe, specifically Americans, that do not have healthcare coverage (insurance). Approximately 26 million Americans are reported by the Centers for Disease Control (CDC) as having no healthcare insurance; which is about ten percent of the 65 and under (age) estimated population of 272 million.

In March 2016 there were approximately 12 million people covered by the exchanges (10 million of whom received subsidies to help pay for insurance) and 11 million made eligible for Medicaid by the law, bringing a subtotal of 23 million people insured. On October 12, 2017,  President Trump decided that he would end the smaller of the two types of subsidies under the ACA (Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act or nicknamed Obamacare), which is the cost sharing reduction (CSR) subsidies.

The decision Trump made, (much like everything he tends to do and/or say) caused controversy and mixed reactions as the decision significantly raised premiums on the ACA exchanges along with the premium tax credit subsidies that rise with them. The Congressional Budget Office (CBO) estimates a $200 billion increase in the budget deficit over a decade. The amount of individuals that had healthcare coverage (insurance) across all demographic groups and congressional districts when Obamacare care initially rolled out and subsequent years before legislative change, was the lowest BEFORE Trump decided to extinguish the subsidies.

For better understanding, the CSR subsidies are paid to insurance companies to reduce copayments and deductibles for a smaller group of ACA enrollees, those earning less than 250% of the federal poverty line (FPL). The second and larger type of subsidy, the premium tax credits, are designed to reduce the post-subsidy cost of monthly premiums, and apply to all enrollees earning less than 400% of the FPL. Essentially, it reduces the out-of-pocket exposure for eligible enrollees. As of 2018, there are more than 5.6 million exchange enrollees receiving cost-sharing reductions. However due to President Trump’s argument that the CSR payments were a “bailout” for insurance companies and therefore should be stopped, results in the government paying more to insurance companies ($200B over a decade) due to increases in the premium tax credit subsidies.” Great job President.

It should come as no surprise that affordability and accessibility play a huge factor in the utilization of PrEP. Research shows that among the United States, only New York, Massachusetts, Rhode Island, Washington and Illinois had the highest PrEP usage rates. Additionally, other notable statistics include:

  • There were 61,300 individuals nationwide that had active PrEP prescriptions in the second quarter of 2017.
  • Regionally, The Northeast, had the highest rate of PrEP use.
  • Estimates show that only 5% of the 1.2 million individuals indicated for PrEP benefit are potentially receiving PrEP protection.
    • That’s only 60,000 people who received PrEP out of 1,420,000 individuals, collectively grouped as 1.2 million that were indicated as benefiting from being on PrEP.

Outside of laws, having the ability to not just afford but obtain medical care and insurance, comes other areas to discuss. What happens, after you get PrEP? Adherence to any medication is simply crucial. Adherence means “attachment or commitment to a person, cause, or belief.” Research studies regarding PrEP adherence are generally either based on adherence in a placebo-controlled group or open-label. Open-label use suggest more of a real-world utilization of PrEP. While there is little research regarding the actual statistics of adherence among PrEP users, valid research does strongly indicate that positive outcomes from PrEP use is directly proportional to adherence. Adhering to any treatment designated by your physician is generally regarded as an important factor in achieving optimal outcomes.

Adherence to PrEP is not only beneficial for the individual taking it, but it also helps in decreasing drug resistance. This is also why it is recommended that in order to receive PrEP, an individual must be negative for HIV-1 and have subsequent testing (at least every three months) afterwards. HIV-1 resistance substitutions may emerge in individuals with undetected HIV-1 infection who are taking only PrEP (Truvada).  Specifically, individual mutations eliminate the activity of tenofovir and emtricitabine. Individuals with HIV can be on anti-retroviral therapy (ART) and Truvada (PrEP) is used in HIV treatment regimens, however traditionally with other ART medications, not by itself.  Thus, PrEP could potentially induce drug resistance in patients who contract HIV while using PrEP and don’t escalate therapy to ART promptly after infection.

Also, high-risk behaviors for both HIV infection and inappropriate medication use tend to overlap. It’s important to be mindful that PrEP is not a cure or type of vaccine. Sexually transmitted diseases/infections can be transmitted to anyone who engages in oral, anal and/or vaginal sex, as well as genital skin-to-skin contact. Regardless if you decide to take PrEP or not, if you are sexually active, practicing safe-sex (such as consistent and correct use of a condom, dental dam, and getting tested consistently) has been correlated with lower infection rates. Abstaining from sex and sexual activities, is really the only sure way to stay clear of any sexually transmitted disease/infection.

However, I take this moment to acknowledge that condom use is not favorable among some, specifically individuals aged 15–24 years, as they account for half of all new STD cases that have been reported. I will save my personal insight for another article, as I have much to say, and I’m definitely not judging anyone that decides not to use a condom. Particularly since there are a variety of reasons why individuals choose not to do so. I do encourage all to make a fully informed choice or be surrounded by individuals that can assist in formulating the best “sexual plan” that best suites you. At the end of the day, YOU ultimately will be the one that has to live with whatever outcome: not me, nor anyone.

Navigating the healthcare world can be difficult, particularly those with low-income and minimal access. I encourage everyone with the ability to access the internet to do their own research. The world can only become better in a holistic capacity, the more informed we are about its realities. It shouldn’t be “taboo” to discuss topics such as what has been previously discussed. Quite frankly, the silence we have on such topics is probably why many young individuals account for half of all new STD diagnosis. Silence is the reason there have been and continue to be, myths (stigma) perpetuated regarding HIV transmission. You can’t get HIV by touching someone, or their sweat, saliva, or pee. You can’t get HIV by breathing the same air, touching a toilet seat or door knob or handle, drinking from a water fountain, hugging, kissing, or shaking hands, sharing eating utensils or using the same exercise equipment at a gym. You can get HIV from infected blood, semen, vaginal fluid, or breast milk.

I also encourage individuals to take a look at The U.S. Preventive Services Task Force (USPSTF) recent recommendation for PrEP. The USPSTF, is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This is the first time doctors are being urged to offer PrEP to patients who are at risk for contracting H.I.V. The recommendation, not only is graded the highest possible by the USPSTF (Grade A), but also includes all men and women whose sexual behavior, sex partners or drug use place them at high risk. This is crucial as approval of this recommendation, would greatly expand access to the $20,000-a-year drug regimen. If you would like to review and/or submit a comment, the recommendation will remain open to the public for until 12/26/18. The full draft can be viewed by clicking the following link:

Draft Recommendation Statement Prevention of Human Immunodeficiency Virus (HIV) Infection: Pre-Exposure Prophylaxis

Will you PrEP? Feel free to leave a comment expressing your thoughts, or utilize the contact and send a private email.

  • Alex N. Wanderland

 

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Author Note: There have been reports of individuals contracting HIV while on PrEP. I did not discuss this in this article as I did not want it to be entirely lengthy and I personally feel, for lack of a better phrase, “the good outweighs the bad.” However, I may do a subsequent article solely talking about the cases, side-effects of PrEP, and other topics that may be considered useful in properly informing about the cautions of PrEP usage. HOWEVER, DO YOUR OWN RESEARCH! In the event that I do not do the article, I do wish to share two articles I found:

PrEP Fails in Gay Man Adhering to Daily Truvada, He Contracts Drug-Resistant HIV

PrEP Fails in a Third Man, But This Time HIV Drug Resistance Is Not to Blame

These articles, to me, showcase the common ying-yang relationship involved with a lot of things in life, and PrEP is no exception. It is a GREAT resource pending you actually: need to use it, can access it, adhere to it, afford it, and can truthfully evaluate your sexual life and desires.

 

Disclaimer: Alex N. Wanderland is not a scientific expert but is a current student in a STEM degree program that explores various topics in branches of science such as Molecular Biology, Biotechnology, Genetics, Immunology, and Virology. Alex has personally performed laboratory skills such as CRISPR, PCR, RT-PCR, Western Blotting, Southern Blotting, and Enzyme Linked Immunosorbent Assay (ELISA), to name a few. Alex continues to actively enhance his depth in a variety of branches of science and this article is one of many ways in which exploration has taken place.