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Advocates: HIV case should not cast doubt on PrEP effectiveness
by Matt Simonette

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Researchers at the Conference on Retroviruses and Opportunistic Infections ( CROI ) in Boston, on Feb. 26, reported that a Canadian man, who had been using the medication Truvada for pre-exposure prophylaxis, or PrEP, had been infected with HIV. It was the first reported case of an individual with full compliance to a Truvada for PrEP regimen getting HIV.

Truvada has been reported as being up to 92- to 99-percent effective in reducing that risk; researchers currently estimate about 40,000 persons are using Truvada for PrEP.

But news of that infection, while calling for some reflection on individual sexual practices, should not take away from the fact that PrEP has served to protect "tens of thousands" from infection, said Jim Pickett, director of Prevention Advocacy and Gay Men's Health for AIDS Foundation of Chicago.

"There's no such thing as a 100 percent-safeguard," said Pickett. "That's why we've always said that Prep is up to 99 percent effective in preventing infection. … Now we have one case out of 40,000 individuals and many drug trials. We can still say confidently that PrEP offers a considerable amount of protection."

The patient, whose identity was not made public but was identified with the first name "Joe" in a March 3 interview, was infected with an HIV strain that was resistant to both emtricitabine and tenofovir, the two main components of Truvada. Joe began taking Truvada in early 2013 and had adhered to the prescribed daily regimen. In early 2015, he became ill with persistent stomach issues and his infection was discovered thereafter. He immediately began treatment to reduce his viral load.

"I said, 'Let's nip it in the bud,'" Joe told . "He put me on a very strong course of medication, and within three weeks my viral level disappeared. Now I'm on a different course of HIV medication, just once a day, in the morning."

Cori Blum, MD, medical director at Howard Brown Health's Sheridan Road location, also said that news of Joe's infection should not change the message about PrEP.

"PrEP is extremely effective—we can't say 100 percent, because here's a case where it wasn't effective—but nearly 100 percent effective if the medication is taken daily," she added. "It's important for people taking PrEP to be aware of this very small risk. It highlights that knowing the HIV status of your partner or partners could be useful in gauging the vulnerability to infection. But I don't think we need to change what we're saying about PrEP being effective and preventing HIV transmission. This is a rare event, but it highlights that people on PrEP need to take their medicine daily, get tested for HIV, pay attention to their bodies and stay connected with their medical providers."

Advocates and healthcare providers have faced numerous challenges disseminating messages about PrEP since Truvada was approved for that purpose by the Food and Drug Administration in 2012. Among their hurdles have been the high cost of the drug—a month's supply is about $1,600—as well as insurance difficulties, low community and physician awareness and stigmatization around perceived promiscuity.

Blum said there should indeed be more urgency focused on getting PrEP into the hands of individuals whose communities are being disproportionately affected by HIV. Researchers for the Centers for Disease Prevention and Control ( CDC ) said at CROI that, if infection rates remain constant, one out of two Black gay men will at some point be diagnosed with HIV, as would one out of four Latino gay men. CDC projections indicate that those numbers would be significantly reduced if those communities had greater access to PrEP and other safer-sex measures.

"Rather than doubting the effectiveness of this wonderful tool that we have in PrEP because of this case, we have to be strong about its effectiveness and use, and be expanding access as much as we can," she said.

The interview is at .

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