As the first episode in “HIV Matters,” Dr. Falk welcomes Dr. Christopher Hurt for a discussion on preventing HIV with PreP. Dr. Hurt talks about what PrEP is, how to get it, and who might want to consider using PrEP. Dr. Hurt is an Assistant Professor of Medicine in the Division of Infectious Diseases and is Co-Director of the North Carolina AIDS Training and Education Center.
– Dr. Christopher Hurt
Specific Topics Covered:
- Awareness of HIV Risks and Prevention
- How to Get a PrEP Prescription
- Embarrassment Talking About PrEP
- PrEP as an HIV Insurance Policy
- Current Research in PrEP
Ron Falk: Hello, and welcome to the Chair’s Corner from the Department of Medicine at the University of North Carolina. This is our new series for patients where we talk about HIV. We’ll begin the series by talking about prevention, and specifically, the prevention pill known as PrEP.
We welcome Dr. Christopher Hurt, who is an Assistant Professor of Medicine in our Division of Infectious Diseases. He is also the Co-Director of the North Carolina AIDS Training and Education Center. Welcome, Dr. Hurt.
Hurt: Thank you.
Awareness of HIV Risks and Prevention
Falk: Dr. Hurt, you have been helping patients who have HIV, and you also help people who do not have HIV and are trying to prevent it. How do you help people understand the risks of getting HIV?
Hurt: Things have changed a lot. There is still a public consciousness that HIV is a death sentence, for a lot of people, especially in North Carolina in rural areas where in years past people had family members that may have died of AIDS, and so there’s this sense that it’s a death sentence. It’s really not that anymore. A lot of what we do is just educating about where the state of the epidemic is, and the state of treatment, and helping people understand what living with HIV really means.
Falk: Even with all of the public personas on TV, the Magic Johnsons of the world who clearly are doing quite well, it’s difficult to penetrate the idea that with modern therapy one can live almost a normal life.
Hurt: That’s right, and the data are really clear that life expectancy for people who acquire HIV now is approaching that of the general population, so it really is night and day from the early days of the epidemic.
Falk: What would you advise people to do to prevent getting HIV?
Hurt: For many years, basically the only thing we could tell people would be, either you’re abstinent from sexual activity, or use condoms consistently. That generally works. We know that both of those things work. However, there are a lot of people for whom condoms are a deal breaker. They don’t like using them, there are a lot of people who describe that the feeling of sex is very different with a condom, and so it was very frustrating for those of us in HIV prevention to counsel a patient and say, “Well you need to either use a condom consistently or be abstinent.” They would say, “Well, I don’t like using condoms.” So, my answer was, “Well, you have to use a condom.” It was this loop. It was really frustrating.
Now, we have another option, and that’s PrEP. PrEP is pre-exposure prophylaxis. The idea is actually an old idea, it comes from malaria. If you’re going to a part of the world where there’s mosquitoes with malaria, and you take malaria pills before you get there, and you get bitten, you have drug in your system waiting to kill the malaria before it sets up shop. We’re just bringing that idea forward and applying it to HIV, so that you take HIV medicines before you run into somebody who might transmit HIV to you, and you have medication that’s waiting to kill the virus before it has a chance to establish an infection. It’s basically now another option in our toolbox that we can offer to people, so that now instead of having abstinence, condoms, and those being the only two options, now we have additional options to offer people.
How to Get a PrEP Prescription
Falk: How does somebody get it? You can’t just walk up to your local drug store and find PrEP over the counter.
Hurt: Right. It’s prescription-only right now, and that is for the foreseeable future, there’s no real concerted effort to try to make it over the counter. So, it does require a prescription. But it’s not that it requires a specialist, and that’s been a challenge for getting PrEP out there in the community, is there was a perception early on with PrEP that it really needed to be an infectious disease or HIV specialist that prescribed it.
Falk: It can be anybody.
Hurt: It can be anybody. So, I think, over time, we’ve kind of realized that anybody who could prescribe birth control pills could prescribe PrEP. There’s a lot of overlap for who would be a good candidate for birth control pills and who’s prescribing birth control pills. PrEP was initially described as the blue pill, the birth control pill for men. It’s not—it doesn’t do anything for pregnancy prevention, but it’s very much in that same vein of talking and thinking about sexual health and how you can be more proactive about it.
Falk: Is there one dose, or are there different doses, or is it one pill?
Hurt: Yeah, it’s one pill. The brand name is Truvada and currently there is only one drug approved for pre-exposure prophylaxis in the United States, and that’s Truvada. There are others in the pipeline. It’s quite a big pipeline coming and a lot of things that are being studied, but that’s currently the only one that is available.
Falk: Is it expensive?
Hurt: It’s fairly expensive if you had to pay out of pocket. Depending on the pharmacy, the retail price is somewhere between $1,400-$1,700/month, but it’s really important to keep in mind that very few people actually have to pay the price out of pocket. The manufacturer has a really nice assistance program for people, and most insurance covers it because it’s FDA-approved for this indication. If you meet the right eligibility criteria for PrEP, it will be covered by your insurance company with a standard copay.
Falk: But you have to take it every day.
Hurt: That’s right, daily adherence is really important.
Falk: Is that the same for men and women?
Hurt: Yes, it gets up to speed basically for anybody who is having receptive anal sex. They are protected after five to seven days of consecutive dosing. For women, for vaginal and cervical protection, it takes about twenty days. That’s just because the tissues soak up the drug at a different rate for women than they do for men, or women who are having receptive anal sex.
Embarrassment Talking About PrEP
Falk: Do you get patients who are may be embarrassed to ask the question, to get over their embarrassment and say, “Hey, I need some of this prophylactic therapy?”
Hurt: Yes, that’s a big challenge, and I do a lot of trainings around the state with providers to help them understand how to do PrEP and how to deliver PrEP. A lot of them ask, “Is there something I can put in the waiting room, like a checklist or a discussion starter? Something of that nature, where I don’t have to be the one to bring it up with the patient, the patient brings it up.” I have some kind of philosophical issues with that because I think that you should be thinking about sexual health with your patients, even if it’s not in the right context. If they’re there for a blood pressure check, it’s probably not the right time to talk about your sexual health, but if it’s a general wellness visit and you have some opportunity to talk to your patient about it, I think that’s appropriate.
I really think it’s important for a patient, if you think it’s right for you, and you’ve done a little bit of due diligence, kind of checking around, researching on your own, I think it’s important to bring it up. There’s a lot of good resources online that patients can look at and print out, and potentially bring to the visit as the discussion starter. I think also, as a patient, if you’ve really built a relationship with your provider and you feel comfortable enough to talk about sexual health issues at all, then I think this is definitely in that same ballpark. You should feel okay about bringing up the issue, or the topic of PrEP with your provider.
Falk: I have not seen a Truvada ad on TV.
Hurt: Yes, it’s a very interesting area, because the company that manufactures Truvada, they were very concerned about marketing a drug that it’s only purpose was a sexual health purpose. So, unlike drugs for Hepatitis C, from the same manufacturer, that are all over TV now, it’s a little thornier to do the marketing for Truvada, so they really shied away for the first year or two after FDA approval. They were really reluctant to do any marketing. That’s slowly changing, so now it’s starting to do some detailing with providers—visiting primary care offices and federally-qualified health centers to talk to providers about what PrEP is, and do some general… the regular thing you would expect from pharm reps. In terms of ads on TV, not really there. It’s in some print media, and in some online media, especially blogs for the LGBTQ community and web sites for that community, but there’s not a whole lot otherwise in terms of marketing.
Falk: Lots of people are just not going to be comfortable walking up to their usual doctor or nurse practitioner and saying, “Hey doc, I need Truvada.” They’d be much more comfortable going to a physician who is well-attuned to these issues. How do you find that kind of person in the state of North Carolina? Somebody who knows about this drug, who counsels people, who are worried about HIV or other sexually transmitted infections? Where do you find them?
Hurt: I work with the North Carolina AIDS Training and Education Center. It’s a training center here at UNC, and our purpose is to help providers get trained on issues related to HIV, both treatment and prevention. At the end of 2014, we created a map that you can search to find a provider that’s in your area.
Falk: Is that map online? How do you find it?
Hurt: Go to www.med.unc.edu/iamprepared. If you go there, it has some general information that’s geared towards consumers about what PrEP is, what it means, who’s right for it, and has our searchable map that you can identify what practices are local to you. All of the folks on that map either approached us wanting to be listed because they were already doing PrEP services, or they’re folks that we trained, so it’s essentially a vetted list of providers in the state. Just in the last couple of weeks, there’s now a national version of that map that’s available also. If you happen to have friends or loved ones in other areas that you think might be good candidates for PrEP—that’s called “PleasePrEPMe.org.” That’s gone live just in the past couple of weeks. It’s a truly national view of what those resources are.
Falk: That’s great.
PrEP as an HIV Insurance Policy
Falk: When you talk about sexual health, Truvada or PrEP only prevents HIV transmission, it does not work for any of the other viral or other diseases one can get with unprotected intercourse—doesn’t stop herpes, doesn’t stop syphilis, doesn’t stop gonorrhea, none of those.
Hurt: That’s right. That’s really important to point out. It’s really a recommended piece of the counseling for patients when they’re thinking about starting PrEP. This is laser-focused, it’s just HIV. So, we still recommend that people use condoms, because we know that they’re really good at preventing the other STIs. All of the other bacterial STIs, like gonorrhea, syphilis, chlamydia, other viral STIs like herpes—condoms and barrier protection work really well for that. This is basically to protect you against just HIV infection and it can be in the context of either an insurance policy if you’re using condoms consistently already, but if you may be having sex with someone who’s living with HIV right now, and if you’re concerned about acquiring HIV from them, using Truvada may be your backup policy in case the condom breaks, or if in the heat of the moment, there’s not a condom available. That’s one way of looking at it.
There are also people for whom PrEP has really represented sexual liberation, so they make a conscious decision that, I’m okay with the risk of getting these STIs, but I know I’m protected against HIV, the very serious and incurable STI.
Falk: The problem is, of course, that some of those other sexually transmitted infections carry all sorts of long-term complications all by themselves. How do you tell somebody you don’t need to use a condom anymore if you use PrEP but, you really need to use a condom still to prevent other diseases, especially if you’re not monogamous?
Hurt: The example that I would give for this is patients that we have in care, where, say a husband and wife, where maybe the husband acquired HIV either through sex or drug use, and they stopped having sex—the husband and wife stopped having sex period, because they were concerned about transmission, and the risk even with a condom was unacceptable, unacceptably high. Now we have PrEP in the mix, so what that’s done in the relationship is reset things, and we definitely have couples in our clinic that fell into that category. They stopped having sex completely, and now that intimacy has been restored, thanks to PrEP, because the wife or the husband has started on PrEP and now they feel like, Okay, if the condom breaks at least I have this backup policy, basically. A backup insurance policy.
Falk: Coming back to something though, you said it really doesn’t work in the heat of the moment unless you’ve been taking it—males, five to seven days, females at least twenty days, right? It must be a pre-planned heat of the moment.
Hurt: We know that consistent dosing of PrEP is the best way to do it. We counsel patients that when they’re starting on PrEP, that daily dosing is what we really should strive for.
Falk: So, patients are taking this every day—are there side effects of this drug?
Hurt: Yes, there is a start-up syndrome that is described for a small but significant portion, maybe ten to fifteen percent of people who start on PrEP. You get a little headachy, a little gassy, and you may have a little bit of nausea. For the vast majority of those, the ten to fifteen percent of people, that tends to go away within two to three weeks of dosing. Once it gets up to speed in your system, those side effects go away.
Falk: Once you’re on it, are people generally happy, comfortable staying on it?
Hurt: Yeah, I think they are. It’s different for different people. There’s a term that was coined a few years ago called a “season of risk,” with the idea being that if you’re in a stable relationship with somebody, and you’ve both been tested and you’re both negative, that maybe it’s safe to forgo condoms in that setting. But, if you should break up and then you’re having sex with new partners again, now you’re in a new “season of risk,” and that PrEP might be appropriate in that context. You can safely stop and start it, it doesn’t lose its oomph if you start and stop and start again.
I think that the majority of people who start on PrEP are able to strike the right balance for them, in communication with their provider about what their circumstances are, to try to determine when it’s the right time to be on it, and when it’s okay to stop.
Current Research in PrEP
Falk: The FDA has approved PrEP, as you talked about it’s a once a day pill, Truvada. UNC marked a milestone this year by opening three new PrEP studies for enrollment. Can you tell us a little bit about these studies and why it’s important to have options when it comes to PrEP?
Hurt: Yes, and this is a really important topic I think, because UNC has really been at the heart of important discoveries over the past few years related to HIV prevention, and we’re continuing to contribute with these three studies that we’re doing now. One of them is looking at Truvada versus the “new and improved Truvada.” There’s a new version that has some adjustments in the potential for side effects for people taking it. It’s a cleaner version essentially of the existing Truvada. The hope is—the new version is called Descovy—that Descovy will be just as good as Truvada for purposes of prevention. That’s one of those three studies—that study was called Discover. The data from that should be presented within the next couple of years.
The second study is one that is looking at whether or not an injectable form of an HIV medication that lasts for about two months, if that one might be just as good as oral dosing. That opens up a whole bunch of options for people who might not want to take a pill every day, or have concerns about privacy or confidentiality being observed taking a pill every day. That study is in the HIV Prevention Trials Network—it’s called HPTN 083. That study is ongoing.
Then there’s a third study that’s a little bit outside the box, but it’s giving people an antibody that grabs on to HIV. That study is called AMP, or Antibody Mediated Prevention. That study is also in the HIV Prevention Trials Network. The idea there is that you come in, you get an infusion of this antibody, it lasts for about two months—similar to the duration of that other injectable medication—and then you’re protected during that time because you have antibodies circulating in your system, that if you should become exposed to HIV it’s waiting to grab hold of HIV and neutralize it.
A colleague of mine here at UNC, Cynthia Gay, has a really nice slide and presentation that she gives showing all of the different options that women have for pregnancy prevention—IUDs, rings, injectables, implantables, the pill—and slowly but surely we’re building that same kind of menu of options for HIV prevention, with the goal really being that we want people to be able to select from a broad menu, something that’s going to reliably keep them from acquiring HIV, but also works in the way they want it to, so they’re not constricted to one or two options and they can pick something that works that they want it to, and that they can go about their lives however they want.
Falk: That’s really exciting. Thank you so much for spending time with us today.
Hurt: Thanks for having me, I appreciate it.
Falk: Thanks so much to our listeners for tuning in to this podcast. In our next episode, we’ll be joined by Dr. Claire Farel, who will talk about ways that a person who has HIV can stay healthy. If you enjoy this series, you can subscribe to the Chair’s Corner on iTunes or like the UNC Department of Medicine on FaceBook. Thanks so much.
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