At last year's Melbourne AIDS conference, every state and federal health minister in Australia pledged to eliminate HIV transmissions by 2020. While there's been a suite of measures set in place to achieve this, there's one thing missing: and that's widespread access to PrEP (or Pre-Exposure Prophylaxis), facilitated with a drug called Truvada.
PrEP is a preventative measure that uses a number of antiretroviral medications to prevent the spread of HIV within HIV negative people. If taken daily, studies have shown this dramatically reduces the risk of HIV infection, and for a lot of gay men, this drug is a game-changer.
Considering that there's still no known cure to HIV or AIDS, and with the last Kirby Institute HIV Surveillance Report showing that Australian HIV rates were at a 20-year high, the widespread adoption of another preventative healthcare measure seems like a no-brainer.
But it's not that simple.
Truvada is an American drug that can be accessed by Australians in a number of ways. Right now, this drug is already registered for use here by people living with HIV, along with those undergoing PEP treatment (Post-Exposure Prophylaxis, taken 72 hours after exposure to HIV). The USA is the only country in the world to have approved it nationally, which we've explored in our latest documentary, The Truvada Revolution.
However, for it to be registered nationally for PrEP usage (where it could help reduce transmissions), it needs to go through lengthy scrutiny at the Therapeutic Goods Administration. After that, there's another substantial wait for it to be considered for subsidisation under Australia's Pharmaceutical Benefits Scheme.
Truvada's manufacturer, Gilead, recently submitted it to the Therapeutic Goods Administration for registration, but estimates place a response mid-way through 2016 (it's currently at it's pre-approval stage). For medical practitioners like Edwina Wright, this wait might be a touch too far.
"The TGA's a really honourable institution because of their exceptional standards, but at times it can be a little frustrating when you've got such a panoply of positive science about Truvada's efficacy," Edwina told VICE.
Edwina's the project leader of VicPrEP, one of three Australian studies into the use of PrEP among gay men, the other two in New South Wales and Queensland. This is one way that some gay men have accessed Truvada at present.
But they don't need the trials or the TGA's approval to be taking it. If someone consults with their GP, they can get a script for Truvada or its generic drug equivalent. The only catch is the cost. A month's supply of Truvada ranges from about $1000, to around $300 for the generics.
While there's a number of generic drugs that bodies like the Australasian Society for HIV Medicines (ASHM) recommend, it's going to be Truvada's registration with the Therapeutic Goods Administration that will open the floodgates, because that sets it up for potential subsidisation.
This presents an unnecessary wait for men who want to stop the transmission of HIV ASAP. This is the case for Phil Joffe, who's been using generic PrEP medication for almost a year now. He's recently been admitted into the VicPrEP study.
Before his entry into the study, Phil was importing the drug from a generic manufacturer from his native South Africa. For him, he's always found condoms cumbersome, and based off his past experiences, PrEP was the next logical step to ensure protection while going bareback.
"Taking this drug has been an incredibly liberating experience because I'm not having to discount HIV positive men who don't need to be discriminated against because of their illness," he said.
But the kinds of positions that Phil touches on haven't come without controversy. The Victorian AIDS council believes that Truvada won't be replacing the condom anytime soon, but will provide an alternative for those "who cannot consistently use condoms". There are risks involved by doing this, and it's primarily got to do with adherence. Much in the same way that we haven't achieved 100 percent condom usage, we also can't guarantee everybody will strictly adhere to taking a pill a day. But for researchers like Edwina, arguing against one over the other is an unnecessary zero-sum game.
"Well look, it's just like refusing to buy a car with seat-belts because it has airbags instead. Why wouldn't you try and use both as much as you can?," she said.
While current debates about PrEP in Australia can largely be pinned to economics and logistics, the road leading us to this point means defining gay sex, which has gotten vicious— something our siblings in the US have written about.
But unlike debates in America—where a significant number of campaigners have warned against sexual promiscuity with the label 'Truvada Whores'—Australia's discussion has largely gone unscathed.
"Truvada's backlash hasn't really occurred much because we have really close working relationships between community organisations, the doctors, and scientists at ASHM, so we're always getting everybody on board to understand what this all means. This didn't leave space for the same kind of ugliness that came out in America," said Wright.
To policy analysts, the notion of collective ownership over PrEP's benefits to Australian society is one fundamental difference that has avoided its controversial introduction in places like the US.
"Australia is probably closer to having Truvada approved for PrEP than any other country at the moment," says Heath Paynter, policy analyst at the Victorian AIDS Council.
"Australian AIDS organisations have really worked closely with the community to garner considerable media attention for PrEP as a prevention strategy." But along with Paynter, nobody's naive enough to believe its adoption will come anytime soon.
"There's a lot of pressure on the health budget at the moment so there's going to be a need for advocacy to demonstrate the cost-effectiveness of this measure," says James Gray, manager of gay men's sexual health programs at ACON (formerly the AIDS Council of NSW).
One way to potentially do this is to understand the fundamental shift that PrEP will have to HIV positive and negative people, along with legislators. Up until now, the onus has largely been on HIV positive people to keep transmission in check. An unfortunate by-product of this meant that some have been made the unfortunate villains of HIV prevention, leading to shame and discrimination because of their incurable illness.
PrEP practices could change this.
"The regular use of Truvada makes HIV prevention something that is as much the responsibility of the HIV negative person as the HIV positive person," says Paynter.
But for younger generations of gay men, the HIV narrative has been one of extremes leading to an unnecessary dichotomy between those who are "clean" and those who aren't. On the one hand, there's a nurturing argument that speaks of self-care, consent and awareness. On the other, there's a veneer of continual fear and mistrust as you're told to never assume that a sexual partner is HIV-free. For them, the "shadow of the grim reaper" is a legacy that's not easily shaken off, according to 22-year-old Brandon James Cook.
"That's exactly it! And it all comes back to that doomsday scenario, doesn't it? Even if you're straight—although I think it's worse if you're gay—there's the whole 'you're an AIDS-ridden sodomite' factor that people like to throw at you," he said.
While this hasn't phased Cook, he says he can't help but shake off "some fear or uncertainty", adding, "When you read about HIV—oh boy. Yeah, that's gonna haunt you. Every single time".
PrEP then, presents a new way for Australian gay men to escape the fear and anxieties that come with sex. But when faced with potential costs of up to $1000 dollars, accessing a simple pill to stem the contracting of HIV is easier said than done. If Australia honestly wants to have no new HIV transmissions by 2020, widespread access to PrEP may need to come a lot sooner.
Follow Alan going on Twitter: @alnwdn
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