PrEP Open House Promotes Access

Nearly 100 people gathered at the Eureka Valley Recreation Center in the Castro recently to learn about the latest research on HIV pre-exposure prophylaxis, or PrEP, and how they can get it.

"Every day more San Franciscans are accessing PrEP, but only one in six people who could benefit are getting it," said Tim Patriarca, director of gay men's health and wellness at the San Francisco AIDS Foundation, which organized the January 11 open house.

SFAF's medical director Dr. Robert Grant of the Gladstone Institutes gave an overview of the latest scientific data on PrEP. Gilead Sciences' Truvada (tenofovir plus emtricitabine) taken once daily is currently the only PrEP regimen approved by the Food and Drug Administration, but several others are under study.

"PrEP works if it's taken, and there's some forgiveness for an occasional missed dose," Grant summarized. "We cannot make any guarantee that someone taking PrEP won't get infected, but it if happens, it's rare."

An open-label extension of the international iPrEx trial saw no new infections among gay and bisexual men whose blood drug levels indicated that they took Truvada at least four times per week. While only about one-third of trial participants managed to achieve this level of adherence, San Francisco's PrEP demonstration project, conducted by City Clinic, found that 92 percent took Truvada at least that often.

"We want to get beyond the notion of risky people," Grant said. "There are risky situations, and people move in and out of risky situations."

PrEP Users Speak

A panel of PrEP users described their experience using Truvada for prevention under different circumstances.

A woman who was identified in the program as Poppy Rock (and who said that is not her given name) said that she took PrEP while trying to conceive a child with her HIV-positive husband. Her primary care doctor refused to provide PrEP and would no longer treat her if she used it. Her mother said she would not be happy about the pregnancy until the woman received a negative HIV test. Despite this lack of support, the woman gave birth to a healthy infant and is now looking toward "PrEP Baby #2."

Paul Urban started taking PrEP because one of his partners is HIV-positive. Unlike the aforementioned woman, Urban's doctor readily prescribed Truvada and he uses an app to remind him to take it regularly.

"I think as long as I'm able to have sex, I'll be on PrEP," said Urban. "I prefer the intimacy of not using condoms, and we all know that in the heat of the moment, we don't use condoms."

Adam Zeboski, an HIV counselor at SFAF known for starting the #TruvadaWhore meme, has been using PrEP for about two years, starting in City Clinic's demonstration project.

"I started [PrEP] because I care about my own health and my community," Zeboski said. "[I experienced] a drastic decrease in fear, anxiety, and stress."

"When there's something that's beneficial for your health, why not take it as long as you know the risk?" asked Nadji Dawkins, who receives Truvada through the East Bay AIDS Center's CRUSH Project. "Don't let other people's words prevent you from keeping yourself healthy - there's nothing wrong with having sex."

The panel's experiences illustrate the variability in local doctors' willingness to provide PrEP. The Bay Area Perinatal AIDS Center has compiled a list of clinicians who are knowledgeable about and willing to prescribe Truvada for PrEP.

Getting PrEP Covered

A major focus of the open house was how to access Truvada for PrEP, which costs about $1,000 per month. Medi-Cal and many private insurers cover PrEP and Gilead offers payment assistance programs, but restrictions leave many people falling through the cracks.

Bronze level plans available through Covered California (the state's Affordable Care Act exchange) have lower premiums than silver, gold, or platinum plans but require higher copayments and deductibles for services and prescription drugs, explained Matt Sachs of SFAF's Magnet health center. Some plans require a several thousand-dollar deductible before coverage kicks in.

Many bronze plans will not pay for Truvada for PrEP, but during Covered California's open enrollment period - which runs through February 15 - people have an opportunity to select a new plan that provides better coverage.

SFAF, Project Inform, and other agencies have put together a guide to help state residents find plans that include coverage for HIV and hepatitis C treatment or PrEP (http://www.projectinform.org/pdf/CCguide.pdf). An accompanying formulary guide ( http://www.projectinform.org/pdf/CCformularies.pdf) details the availability of specific drugs.

Ruben Gamundi, Gilead's associate director of community medical affairs, explained that the company has a patient assistance program for people who are uninsured, as well as a copay card that covers up to $300 per month. The card is available to anyone and can be obtained at many doctor's offices, pharmacies, and AIDS organizations.

Despite the ACA, many people remain uninsured or underinsured. Some insurance companies have classified Truvada for PrEP as a specialty drug and some require pre-authorization. Also, a federal law prohibits drug companies from offering assistance to people who receive federal benefits like Medicaid or Medicare.

"The city knows this is an issue, and when it funds a PrEP program it is likely to first come up with assistance for people without coverage or who fall through the gaps," said Robert Blue of City Clinic.

Blue and Sachs were recently hired as "navigators" under the city's new program to expand access to PrEP. Initiated by gay Supervisor David Campos and passed by the Board of Supervisors in October, the program received approximately $300,000 for counselors to help people obtain Truvada through existing channels.

Advocates are urging the city to also allocate funding for a PrEP drug assistance program to pay for Truvada for people who cannot get other coverage. Washington state started the first "PrEP DAP" and a similar effort is underway in New York.