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HIV/AIDS in the Age of PrEP: A Funder’s Perspective

In the 30-plus years since the AIDS epidemic began, laboratory researchers have been seeking a cure. This goal would be hard with any major illness that spread like wildfire through certain populations, but it has been made exponentially more difficult due to the HIV virus’ craftiness. HIV mutates faster than any other virus we’ve seen and between mutations and different strains of HIV, research teams have had their work cut out for them.

A vaccine would be the holy grail to stop the spread of AIDS, but a vaccine has proven extremely elusive. HIV has so far evaded efforts to destroy it. Scientists around the globe have been working on a microbicide – a gel that can be easily applied (or applied in secret) and kill sperm as well as HIV on contact. This would be a game-changer in many parts of the world where women are unable to negotiate safe sex with their partners. Recent clinical trials brought disappointing results due the study participants’ spotty adherence to using the gel each and every time. Like antiretroviral medications, consistency and adherence determine the success of these regimens.

Now we have an option available called PrEP, which stands for Pre-Exposure Prophylaxis. PrEP is a combination of two anti-HIV medications called tenofovir and emtricitabine (Truvada), and can be used to prevent someone from becoming infected with HIV if they take it every single day.

PrEP has been recommended for those who cannot or will not use condoms; those who do not know the status of their sex partners; those who exchange sex for money, food or housing; and those who are IV drug users. In other words, PrEP is aimed at high-risk individuals in an effort to keep them from contracting the virus. PrEP does NOT prevent pregnancy, nor does it prevent other sexually transmitted diseases (STD’s), such as gonorrhea, herpes, syphilis, Chlamydia, or HPV.

It’s not a ‘morning after’ pill; those who begin PrEP must take the medication every day as well as have blood work done every three months. It is recommended that no one start PrEP on their own; they should be under the consistent care of a healthcare professional (preferably one with infectious disease experience). Studies have shown a very high rate of success when PrEP is used correctly (lowering the risk of HIV by about 90 percent).

It is important to remember that PrEP was never intended to be a cure-all or magic bullet. Physicians, nurses, and clinicians that work with HIV+ people every day understand that it is another weapon to be used in high-risk individuals to reduce the spread of HIV. It benefits a community, a country, and the entire world to have the lowest amount of HIV in any given area. This reduces the chances of spreading the virus and the numbers of new infections.

Recently, it was reported that an HIV negative gay man in Canada who consistently took PrEP for two years, has now become infected with HIV. The treating physician has confirmed that this patient (who was adamant about his adherence), consistently and correctly took his medication, verified with dried blood spot analysis and pharmacy records. Doctors are now saying that this person was exposed to a strain of HIV that had become resistant to several antiretroviral medications, like the ones that make up Truvada. Further, they report that less than 1 percent of people living with HIV are carrying a strain that is resistant to Truvada, so the effectiveness of PrEP is still regarded as very high (between 90 percent and 99 percent by various estimates).

Today, it is estimated that between 30,000 and 40,000 Americans are on PrEP, a very small percentage of those who might benefit from the regimen. Robust disputes have followed – publically and vocally – about the implications of PrEP with regard to risk-taking and sexual behavior. There are those that feel the use of PrEP will increase risk-taking and have correctly pointed to the rise in various other STD’s. A lot of the discussion surrounding PrEP is generationally driven; many in the older gay community that lived through the ‘bad old days’ of AIDS, watching numerous friends succumb to painful and drawn-out deaths, feel that the safe sex message has been left behind since PrEP became available.

Those on the pro-PrEP side say that while it is imperfect, it is beneficial to those people who are at the highest risk for contracting HIV. Many younger people view HIV as a manageable, chronic illness, not the death sentence it was before the advent of multiple antiretroviral meds and therapies that have been developed in the laboratory. PrEP is also being tested and used in people in monogamous relationships and marriages where one partner is HIV+ and the other is not.

The argument is further complicated by the problems a society (or the medical community) runs into when trying to change behaviors. Getting people to use condoms each and every time they have a sexual encounter is harder than it sounds; teen pregnancy rates bear this fact out every single day, as well as the increase in STD’s, especially in the southern United States.

Since 1995, The Campbell Foundation has funded almost $10 million in HIV research grants in various nonprofit laboratories around the globe. The HIV virus causes premature aging and inflammation in just about every system in the body, so many of these grants have to do with delving into the myriad illnesses that come along with HIV. These associated conditions, or co-morbidities, affect people with HIV immensely.

The number one killer of people living with HIV is now cardio-vascular disease. Signs and symptoms of metabolic disorders, diabetes, inflammation of blood vessel linings, neurological conditions, as well as kidney and liver problems have all been observed, and are now being treated, in those living with HIV even when their HIV is undetectable in blood tests.

More than one half of the HIV+ population in the U.S. is now over age 50 and must deal with the virus in an aging body. While it may not be the death sentence it once was and treatments are available, it is firmly understood that acquiring HIV is not just ‘no big deal’, especially in pediatric patients who will have to live with the virus, and take powerful antiretroviral medications, longer than their adult counterparts.

As funders of this crucial research, we would hope that we could all come together – physicians and clinical nurses, community activists and organizers, those who serve the HIV+ community daily, religious leaders, school administrators, and funders like us – and keep the conversation going. Regardless of your personal opinion or practices, we’re all in this together and it behooves us all to reduce the number of new HIV infections in any given demographic.

PrEP has been an effective tool in stopping the spread of new HIV infections, but as we’ve just seen with the recent report of one resistant strain of HIV, it may just be a matter of time before we hear more instances of this. We must use every tool at our disposal to combat the increasing numbers of new infections in vulnerable populations; one size does not fit all.

As with all major medical decisions, speak to your primary care physician before starting or stopping any medications. Thankfully, research teams such as those funded by our foundation, continue their important and lifesaving work every day. It’s our mission to help make HIV and AIDS history – let’s all make it our personal mission!

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