A report last month from APLA Health, an arm of AIDS Project Los Angeles (APLA), revealed that only 1 in 10 young Californian men who have sex with men (MSM) have used PrEP, the HIV-prevention therapy that can be 99 percent effective in reducing transmission during anal sex with daily use.
That's a remarkably low rate of adoption for a drug that prompted dramatic headlines when it debuted in 2012. And they weren't hyperbolic—following decades of darkness in the fight against HIV, the treatment spurred nothing less than a cultural revolution among gay and bisexual men. It's a vital breakthrough given that 1 in 2 black MSM and 1 in 4 Latino MSM will become HIV-positive in their lifetime at current infection rates.
Getting the treatment to those who need it most requires public education—and last Monday, California made a leap forward in that battle when Governor Jerry Brown signed Assembly Bill 2640, mandating that every Californian who receives a negative HIV test result must be educated about PrEP.
The bill's mandate might seem simple, but it represents the most dramatic step forward for PrEP education by a government body to date, and a de facto endorsement of the treatment by the State of California.
Given the treatment's proven efficacy and wide-ranging support from a variety of medical and activist organisations, something like mandated PrEP education might seem like a foregone conclusion—especially in California, which has the second-highest HIV infection rate in the nation. But while organisations from the Free Speech Coalition (FSC), the nation's largest porn and adult entertainment political advocacy group, to the Los Angeles LGBT Centre and APLA Health have been fighting for the bill this year, PrEP has met opposition from a small group of gay activists, the most vocal among them being Michael Weinstein, the president of the AIDS Healthcare Foundation (AHF).
Weinstein rose to prominence in the 80s and 90s, when his organisation was little more than a small group of friends asking for money on the street. Together, they helped to defeat Lyndon H. LaRouche's Proposition 64, one of the ugliest pieces of HIV legislation ever proposed, which qualified for the ballot in 1986 with 700,000 signatures and would have required those who tested positive for HIV to be quarantined. And despite his admirable record in the fight against AIDS, today, Weinstein might be better known for headline-making statements calling PrEP a "party drug."
As PrEP gained visibility in the years following its debut, Weinstein and the AHF expressed deep skepticism about the treatment's potential as a community-wide intervention, based on data that showed men who enrolled in early studies had a poor track record of adhering to its once-daily dosing. Because of that adherence issue, Weinstein and the AHF have questioned PrEP's readiness "for prime time as a public health strategy." Though an ad campaign from the organisation last year appeared to roll back some of that skepticism, suggesting PrEP is appropriate on "a case-by-case basis by medical providers working in conjunction with their patients," the organisation still opposed its use "as a community-wide public health intervention strategy." Even with that softened stance, they continue to spend considerable amounts of time and money on their years-long public campaign against the treatment.
While real-world rates of adherence to the drug have varied from study to study, many have shown a majority of users adhere to the drug at four doses a week or more. At that level, PrEP has been shown to reduce the risk of transmission by an estimated 96 percent (though a majority of participants in the iPrEx OLE study, from which that figure is derived, did not achieve that level of adherence). It's important to remember that condoms are far from 100 percent effective, too—one study found that 51 percent of new HIV infections among Ontario MSM were via anal sex with a condom. A 2013 CDC study said that gay men who always use condoms have an estimated 70 percent reduced risk of HIV transmission compared to those who bareback. PrEP and condoms are both tools in the HIV-prevention toolkit. The CDC recommends using both, and as it emphasised in its PrEP clinical practice guidelines, we need more options like PrEP, not less.
Activist groups and medical experts alike have been working to dispel anti-PrEP narratives promulgated by the AHF since it began its advertorial and lobbying campaign. Its competing interests rose to an ideological head with AB 2640.
"All too often we believe that well-balanced journalism means we have to give people like Jenny McCarthy and Michael Weinstein a chance to use the media as a megaphone to spurt anti-scientific personal views as facts," Leue said. "Weinstein believes PrEP is bad, when in actuality PrEP addresses and acknowledges the sexual reality we have been trying to ignore to our detriment."
Coming to terms with that reality—that gay men, like it or not, are having risky sex, and that a prevention tool like PrEP is more necessary than ever given that fact—is something that Dr. David Holland has been working to realise. Holland, chief clinical officer at the Georgia Health Department and assistant professor at Emory University, has worked with Leue on more than one occasion to testify on PrEP's efficacy in California.
"The research shows a majority of gay men are having bareback sex," Holland said. "We are trying to make everyone's lives safer within that reality."
Though Weinstein is just one man, his organisation has wide reach. In 2014, the Advocate reported that the AHF issues 14,000 HIV tests each year, employs more than 1,000 people, and provides medical care and services to more than 123,000 people in 26 countries, according to the organisation's website and its most recent tax filings at the time.
When AB 2640 was being debated, Rand Martin, an AHF lobbyist, said in his California Health Committee testimony against the bill that Truvada can be "toxic" and "it does have side-effects." If, for example, "a 45-year-old man who's been married for 20 years, who has a fling and panics and gets tested, and is told that he should try PrEP, he's going to be asked to be prescribed Truvada," Rand said, and that in this scenario, doctors would be "condemning a person who should not be taking it to forever having to take this pill." Rand's comments, which were filmed, were later featured in a video released by the Los Angeles LGBT Centre. But a 2016 report showed that short and medium-term use of PrEP is as safe as aspirin, and PrEP's prescribing guidelines—in the AHF's own words—note the treatment is intended for those who "have not and will not use condoms and are having multiple sexual partners," not men who are having a "fling."
"AHF did oppose AB 2640," wrote Geb Kenslea, the AHF's Communications Director, in an email in response to a request for comment. "In brief, AHF worked to lessen statutory requirements around testing, counselling etc., and felt this bill was unnecessary. Doctors already can talk to their patients about whatever they want—including pre-exposure prophylaxis (PrEP). However, AHF believes a requirement here that a physician must speak about PrEP was overkill." Weinstein did not respond to a request for comment by the time this article went to press.
But without efforts to spread awareness of PrEP, especially among black and latino MSM—of whom 37.1 precent and 28.2 percent, respectively, were unaware of the treatment in the APLA Health survey—the drug's revolutionary potential may never be realised. And among participants in that survey under the age of 22, 41 percent were unaware. "The people who have most embraced PrEP and who have the most awareness of it are gay men in my age bracket," said Dr. Holland, who is 48. "Our annual infection rate is actually doing down." The same cannot be said for younger, marginalised men.
Public health campaigns can only go so far; efforts like AB 2640 may have the ability to make a lasting dent in the HIV crisis among critical groups. "Knowledge is power," said Leue. "AB 2640 not only prevents further infections, but it also helps fight stigma, fear, and prejudice that have for too long reigned against sexual health knowledge."