County backs HIV drug

Su­per­vi­sors want a plan to get the pre­ven­tive pill into clin­ics, but some ex­perts worry it may lead men to stop us­ing con­doms

Los Angeles Times - - CALIFORNIA - By Soumya Kar­la­mangla

It’s been nearly three years since the fed­eral gov­ern­ment ap­proved Tru­vada, a daily pill hailed na­tion­ally as a mir­a­cle drug be­cause it can pre­vent HIV in­fec­tions.

But un­til this week, Los An­ge­les County hadn’t be­gun to spread the word and dis­trib­ute the medicine de­spite be­ing the sec­ond-largest epi­cen­ter of HIV and AIDS in the coun­try.

That’s partly be­cause county health of­fi­cials were un­sure they would get the nec­es­sary sup­port to pro­vide the drug, which has been some­what con­tro­ver­sial, said Su­per­vi­sor Sheila Kuehl.

The pre­ven­tion method, known as pre-ex­po­sure pro­phy­laxis, or PrEP, is much less ef­fec­tive if not taken cor­rectly, and some say it could in­ad­ver­tently in­crease HIV in­fec­tions if it leads gay and bi­sex­ual men to stop us­ing con­doms.

That po­lit­i­cal hur­dle was cleared when su­per­vi­sors de­liv­ered their en­dorse­ment this week. They passed a Kuehl mo­tion that would craft a plan to get the medicine in the hands of peo­ple who need it at county-run and com­mu­nity clin­ics.

“If you have a tool that could help peo­ple not get HIV, it’s com­pletely immoral not to use it,” Kuehl said.

Home to an es­ti­mated 60,000 peo­ple who’ve been in­fected with HIV, Los An­ge­les County will now be able to catch up with other cities — in­clud­ing San Fran­cisco and New York — that have made the drug a cen­tral tenet of their HIV-pre­ven­tion strat­egy, said Mario Perez, direc­tor of L.A. County’s HIV pre­ven­tion pro­gram. About 1,850 peo­ple in the county con­tract the virus each year.

“We’ve al­ways en­joyed a fairly pro­gres­sive, fairly ad­vanced HIV re­sponse, and this is one area

where we’ve fallen be­hind,” Perez said in an in­ter­view Wed­nes­day. “It’s good to know that our pol­icy is on the same side as science.”

He said Tru­vada — man­u­fac­tured by Gilead Sciences — would re­main a piece of the pro­gram’s broader strat­egy, which still views con­dom use as a pri­mary pre­ven­tion method, as well as HIV testing to iden­tify who has al­ready con­tracted the virus.

But AIDS Health­care Foun­da­tion Pres­i­dent Michael We­in­stein warns about overly pro­mot­ing Tru­vada as a public health tool. We­in­stein has been a vo­cal — and con­tro­ver­sial — skep­tic about the drug for sev­eral years. County staff had been re­luc­tant to try to roll out a PrEP pro­gram in part be­cause of push­back from We­in­stein, ac­cord­ing to Kuehl.

Though the U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion say the medicine is up to 92% ef­fec­tive, one study found that peo­ple who took Tru­vada ex­pe­ri­enced a 44% re­duc­tion in HIV in­fec­tion risk. Sci­en­tists said that was be­cause many par­tic­i­pants in the study did not ad­min­is­ter the pill as di­rected.

We­in­stein wor­ries pa­tients won’t take the medicine prop­erly — it must be taken once a day — and then also won’t use con­doms be­cause they think they’re pro­tected. “That will lead to more in­fec­tions rather than less,” We­in­stein said.

He’s not against the use of PrEP, he said. He just thinks it should be con­sid­ered on a case-by-case ba­sis, and that the county should fo­cus its re­sources on those who are al­ready in­fected.

Dr. Mitchell Katz, head of the county’s Depart­ment of Health Ser­vices, said he sup­ported the push to dis­sem­i­nate in­for­ma­tion about the medicine. But he said it needed to be dif­fer­en­ti­ated from other public health cam­paigns that are en­cour­aged for ev­ery­one, such as con­dom use and vac­ci­na­tions.

Pa­tients must de­cide, with their doc­tors, whether PrEP is right for them by dis­cussing the strict med­i­cal reg­i­men and the risks and benefits, Katz said.

“When it comes to PrEP, it’s a dif­fer­ent equa­tion,” he said. “It has to be dis­tin­guished from ‘ev­ery­one should do this’ to a thought­ful dis­cus­sion.”

Al­ready, pa­tients in L.A. County can visit doc­tors who will pre­scribe the medicine, and most in­sur­ance poli­cies cover the cost, which is about $13,000 an­nu­ally.

The plan ap­proved this week will tar­get low-in­come pop­u­la­tions served by clin­ics in the county. Public health depart­ment of­fi­cials were di­rected to cre­ate a plan and re­port back to the board within 30 days. It will prob­a­bly cost about $1 mil­lion, Perez said. Most of the pa­tients that the county ex­pects to treat will qual­ify to re­ceive the drug free or at re­duced cost, he said.

Su­per­vi­sors also added amend­ments to make sure the out­reach is cul­tur­ally rel­e­vant, and to craft a plan to dis­trib­ute the medicine at county jails.

Many ad­vo­cates say the medicine can be a gamechanger, es­pe­cially for high- risk groups such as young peo­ple of color and trans­gen­der pop­u­la­tions.

Be­fore PrEP, the ques­tion was “not if I will be­come HIV-pos­i­tive, but when,” said Gris­sel Grana­dos, proj- ect co­or­di­na­tor in the HIV Risk Re­duc­tion Pro­gram at Chil­dren’s Hos­pi­tal Los An­ge­les, who is on the Pres­i­den­tial Ad­vi­sory Com­mit­tee on HIV/AIDS.

Grana­dos drew a par­al­lel be­tween op­po­si­tion to Tru­vada and op­po­si­tion to the birth con­trol pill, which some wor­ried would lead to risky sex­ual be­hav­ior. Both, she said, are “one of the tools in our tool­box.”

She said she sees PrEP be­com­ing a per­ma­nent part of the na­tion’s battle against HIV along with other kinds of coun­sel­ing and testing. The use of the medicine ac­knowl­edges the fact that peo­ple don’t al­ways wear con­doms, she said, and of­fers an­other level of pro­tec­tion.

Dr. Scott Kim, med­i­cal direc­tor for HIV medicine at the Al­taMed clinic sys­tem, agreed, say­ing the medicine is a way for pa­tients to take their health into their own hands, and should help stem the num­ber of new cases. Next week, Al­taMed — a chain of clin­ics in Los An­ge­les and Or­ange coun­ties — will launch a pi­lot pro­gram of­fer­ing PrEP to high-risk pa­tients.

“If you think about the his­tory of pre­vent­ing and treat­ing HIV, this is one of the first ma­jor tools we’ve had to di­rectly em­power peo­ple at risk of HIV in a way that helps them re­duce risk,” Kim said. “Peo­ple in com­mu­ni­ties who are at great­est risk of HIV tend to be dis­em­pow­ered or dis­en­fran­chised.... Tru­vada is some­thing they can take di­rectly into their own hands.”

Pho­tog raphs by Anne Cu­sack Los An­ge­les Times

PEO­PLE SHOW THEIR SUP­PORT af­ter the L.A. County Board of Su­per­vi­sors voted Tues­day to de­velop a plan to dis­trib­ute Tru­vada, a con­tro­ver­sial med­i­ca­tion for HIV pre­ven­tion, to res­i­dents who are at high risk of con­tract­ing the virus.

SU­PER­VI­SOR Sheila Kuehl said it would be “com­pletely immoral not to use” the drug.

Pho­tog raphs by Anne Cu­sack Los An­ge­les Times

AC­TIVISTS wear shirts bear­ing the num­ber 24,000 at the Board of Su­per­vi­sors meet­ing on Tues­day. The num­ber rep­re­sents county res­i­dents who are not re­ceiv­ing treat­ment for AIDS and HIV, sup­port­ers say.

DR. MITCHELL KATZ, head of the county Depart­ment of Health Ser­vices, speaks at the meet­ing.

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