About David Heitz

David Heitz is a freelance writer who lives in Rock Island, Ill. After working almost 25 years as a reporter and editor at newspapers in Southern California and the Midwest, he is enjoying the transition to the online medium. David writes primarily for Healthline.com, covering HIV and neurology. He is a big fan of social media, his dad and his cat.

Posts by David Heitz:

Scrolling Scruff with PrEP

Scrolling Scruff with PrEP

Jeremy Dykes does not feel bad about enjoying sex without a condom, and those who think he should may be doing more harm than good

By: David Heitz –

Even proponents of PrEP as a prevention strategy stress that the drug is not suitable for everyone. “For PrEP to be cost effective, you have to use it in people at high risk,” Gallant said. “It needs to be used in ways where you can get the best bang for the buck.”

Jeremy Dykes Picture

Source: Jeremy Dykes

Jeremy Dykes of Nashville, Tenn., who began taking PrEP last month, fits the bill as high-risk. He attended the Folsom Street Fair in San Francisco in September. While there, he noted that a majority of guys on Scruff, a gay sex app, noted they were on PrEP in their profiles.

“I’ve always felt like every gay man has to come to their decisions about what precautions they are or are not willing to take to reduce their risk for HIV exposure,” he said. “For some it’s just condoms, for others it’s sero-sorting, still others use PrEP, for most it’s some combination of all of the above.”

Before PrEP, Dykes considered condoms a “necessary evil.” Now? “I don’t feel so bound to ‘em,” he said.

As a sexually active man, he sees nothing wrong with using an HIV prevention method that does not require “real-time thought” in the heat of the moment, like rolling on a rubber.

Still, some gay men in large cities nationwide have labeled guys like Dykes “Truvada whores.”

Gallant finds that reprehensible. “That sounds so much like what people used to say in the 1960s about birth control pills, that women who took them would become promiscuous sluts, and maybe some of them did,” he said. “ But it was an important medical advancement that changed society in a good way.”

Dykes said he doesn’t worry much about the stigma some have attached to PrEP. “It makes me feel safer, that’s all I’m really worried about.” Such a stigma could be preventing some folks who could benefit from PrEP from discussing it with their doctor, however.

“Why is this such a big deal?” said Michael Weinstein, president of AIDS Healthcare Foundation. “Why are we fetishizing unprotected sex?”

A solution for minority infections?

HIV infections among young, gay minorities remain one of the highest in the nation. To that end, Moises Agosto, director of treatment education, adherence and mobilization at National Minority AIDS Council, said there needs to be more discussion about PrEP. “While PrEP may not be right for everyone, and should only be used in close consultation with a medical provider, the HIV/AIDS community and the public health establishment should be doing everything we can to educate people about this exciting new option.”

Gallant noted that the problem among many minority groups becoming infected is that they don’t identify as gay or at risk, so they don’t adhere to prevention methods. He said a similar phenomenon has been found in heterosexual, unmarried women.

“Risk perception plays a significant role in the utilization of prevention strategies in all communities, and certainly we should continue to educate individuals so that they can better determine their own vulnerability to infection,” Agosto said. “At the same time, we know that the majority of infections occur – at least among black gay and bisexual men – in individuals who are out and open about their sexuality.  Our focus should be on how to educate these populations about PrEP and other prevention strategies, rather than focusing on a hypothetical debate about whether it would be widely utilized or not.”

 

STDs and PrEP

One such place where PrEP should be advocated is STD clinics, Gallant said. In those cases, money would be saved over the treatment of HIV, he argued.

He said he has diagnosed patients with HIV and later learned they had been treated for an STD resulting from unprotected anal sex, yet never had been counseled abut PrEP. “If you make an STD diagnosis and not discuss PrEP, you may become partly responsible for an unnecessary infection.”

In some PrEP videos that exist online, there is an implication that PrEP can be used only when needed. This is the sort of thinking that causes Weinstein to fear the emergence of a dangerous new strain among sexually active gay men who don’t properly adhere to PrEP.

“We know that you need to have a few doses in you before you have sex,” Gallant said. “We really haven’t studied that.”

He said he did prescribe short-term use of PrEP to a patient who planned unsafe sex aboard a cruise and at a sex party. “In that person, I thought it made sense. But most people’s sexual activity is not this organized.”

Weinstein pointed out that many gay men are married and monogamous or just plain low-key sexually. “Not every gay man lives life in the fast lane, or lives in Chelsea or West Hollywood. A lot of gay men lead relatively boring lives.”

 

Studies ongoing

Although not many people seem to be talking about PrEP, numerous trials nationwide are underway in Los Angeles, Chicago and around the country.

AVAC: Global Advocacy for HIV Prevention, operates a Web site at PrEPWatch.org which offers detailed information about PrEP. Educational campaigns about PrEP have been launched in Atlanta, Boston, Chicago, Dallas, Los Angeles, San Francisco and New York.

“There is considerable buzz around PrEP within some communities, but it is a relatively new development, so we should expect that it will take time to catch on widely,” Agosto said. “At the same time, some of the controversy surrounding PrEP has no doubt had an impact on the willingness of some health care professionals and organizations to engage heavily around the issue and that’s a shame.”

Agosto noted that all prevention strategies – with the exception of abstinence – are really risk reduction strategies. “None provide absolute protection,” he said. “But when used in combination with traditional prevention modalities, PrEP has been shown highly effective.  Our job is to educate our constituents about all options available to them so that they can make the best decision for themselves.”

Weinstein said he feels the same way, and that is how he has formed his thoughts about PrEP thus far. “My responsibility is to tell the truth as I know it. AHF gets bigger and bigger based on more people becoming infected. I have a responsibility to do all I can to prevent people from becoming infected.”

Although antiretroviral therapy significantly reduces the risk of HIV transmission, there’s a need for PrEP, too, Gallant said.

“There is a lot of tension between the idea of treatment as prevention and PrEP,” Gallant said. “Treatment as prevention means treating people who are positive so they don’t infect others. We need modalities for both positives and negatives for prevention. If you’re a negative person and you have multiple partners, you don’t know if someone is on (antiretroviral therapy) with an undetectable viral load.”

A negative person who is a bottom has to trust the person on top to be wearing a condom, Gallant said. “PrEP puts a person in control as a bottom. An analogy can be made with heterosexual women.”

Why the Leader of America’s Largest HIV Care Organization Wants You to Wear a Condom

Why the Leader of America’s Largest HIV Care Organization Wants You to Wear a Condom

Michael Weinstein remembers popping penicillin to protect against STDs before a night on the town, but PrEP is another story.

By: David Heitz –

 

Inevitably, when people talk about PrEP they also talk about condoms.

For some, the idea of gay sex without condoms — which have proven highly effective against the transmission of HIV when used properly – is blasphemy.

For others, who point to rising infections rates among gay men in the U.S., the idea of continuing to count solely on an old-fashioned prevention measure seems insane. Between 2008 and 2010, more than 50,000 people in the U.S. became infected with HIV, with more than half occurring among men who have sex with men. Among gay men ages 13 to 24, it was a 22 percent spike during that time. Among all gay men, infections shot up 12 percent.

Even government web sites have acknowledged that condoms, when used for anal sex, can break. Meanwhile, people on PrEP who do not use condoms still get substantial protection against HIV if they take the drug correctly, said Dr. Joel Gallant, president of the HIV Medicine Association.

 

Where does that leave us?

“Obviously, there are lots of gay men who are not using condoms,” Gallant said. “Condoms reduce sexual pleasure. Not everybody is willing to do that.”

Michael Weinstein on HIV Prevention Pill PrEP Truvada

source: Michael Weinstein, AHF

Michael Weinstein, 61, heads AIDS Healthcare Foundation, which offers treatment to more than 279,000 people in 28 countries worldwide. It is the largest provider of the HIV/AIDS medical care in the U.S.

What began as a group of friends helping others die with dignity has turned into an enormous organization which has been at the forefront of HIV treatment and prevention. Today, Weinstein oversees a $750 million budget.

He has built the empire, which has improved the lives of hundreds of thousands of gay men with and without HIV through the years, advocating a safe-sex message of condom use. It has been a low-cost prevention method that has worked while AHF has led the charge against the disease.

“There are known ways to avoid contracting HIV, and they are condom use, abstinence and monogamy,” Weinstein said. “We don’t expect people to be abstinent or monogamous, so we promote condom use.”

 

‘A moralist view?’

Gallant said insisting on condom use for everyone is “a moralist view that leads to infections.”

According to the CDC, the number of men who have sex with men who reported having anal sex at least once in a 12-month period increased from 48 percent in 2005 to 57 percent in 2011.

Still, Weinstein does not buy the argument that gay men are not using condoms as often as they once did. “You can do harm by telling a big lie that people don’t use condoms,” he said.

He believes infection numbers would be much higher if people who know they have HIV, in particular, were not using condoms. Still, he noted that half of all of infections occur among those who do not know they have the virus.

The CDC promotes condom use even for people on PrEP. “The CDC, in their language, say the politically correct thing, which is total nonsense of course,” Gallant said. “If you were giving it to people who are using condoms, why would you need it? Unfortunately, that PC language has had way too much pull. I’ve had providers say ‘I’ll only give this to you if you use condoms. That’s not the kind of doctor-patient relationship we want to foster.”

 

Concerns about adherence

“For every sex act where a condom is used there’s virtually total protection,” Weinstein said. “For every act on Truvada for people not taking it, they are 100 percent exposed.”

Adherence levels have been low in the studies. In one study of gay men, the number of those with detectable Truvada in their blood sharply declined from 63 percent the first month to 20 percent by the sixth month on the regimen. Of the 68 men in the trial, 93 percent were black or Latino.

Some PrEP advocates have noted that study participants did not know whether they were receiving a true prevention pill or a placebo, which could have influenced their desire to take the medication.

“You’ve got to be paranoid about your pants falling down to wear a belt and suspenders,” Weinstein said. He noted that young gay men in particular sometimes stay out all night and crash at a friend’s house, thereby not being home to take their Truvada.

Jeremy Dykes of Nashville, Tenn., says adherence is not difficult. “I feel like any methodology that can reduce infection should be encouraged, not panned because of potential adherence problems,” he said. “If the situation is that PrEP is effective but adherence is an issue, then the problem isn’t with PrEP itself, it’s with adherence and that’s the thing that should be studied and addressed. If someone just absolutely can’t take their pill consistently, then their doctor should point them in another direction.”

In the month he has been on PrEP, Dykes said he has not forgotten any doses. He uses his Walgreens app on his phone to remind him to take his pill every morning.    >> Click to download Walgreens Mobile App via Walgreens - Pill Reminder App

 

Condoms only for ‘reckless’ gay men?

So far, there has been no evidence published that supports the idea that men on Truvada have unsafe sex. In fact, there have been reports to the contrary.

Weinstein believes condoms are the best choice for preventing HIV. Period. “At the end of the day, this is not ideological, it’s about the data,” Weinstein said. “The data does not support this as a successful strategy.”

He said he recently had someone tell him he sounds like a mother telling their child to wear a raincoat. He took it as a badge of honor. “What happens when fogys like me stop talking? There’s an element in the gay community that’s really reckless.”

Although an entire generation of gay men have chosen to never have bareback sex due to HIV, Weinstein admits he hails from a pre-condom era.“If every gay man took (Truvada), it would be a huge windfall for (Gilead), but the changes in culture would be catastrophic. I’m old enough to remember when people popped penicillin before a night on the town.”

 

Are Gay Men More Interested in Ecstasy Than a Pill to Prevent HIV?

Are Gay Men More Interested in Ecstasy Than a Pill to Prevent HIV?

Truvada has been approved for 18 months, but few gays are taking it or talking about it. The president of the nation’s largest HIV care provider says that’s because we aren’t interested.

By: David Heitz –

A pill a day to keep HIV away?

It’s true. And it’s unfathomable for some gay men who came of age in era when HIV meant death. For decades, the only way to protect yourself was abstinence or to wrap it up.

That has all changed. Truvada, manufactured by Gilead Sciences, is known as a pre-exposure prophylaxis, or PrEP. Taken once daily, it is highly effective at preventing HIV infection.

According to the U.S. Centers for Disease Control, studies show that people who take the drug once a day, as directed, can significantly reduce their risk of HIV infection. It doesn’t work if it’s not taken every day. Studies show that among men who have sex with men who have detectable levels of medication in their blood, risk of transmission is reduced by more than 90 percent, according to the CDC.

Truvada is a combination of tenofovir disoproxil fumarate plus emtricitabine. Those drugs individually are used to treat people living with HIV, but PrEP is only for people who do not have HIV.

The U.S. Food and Drug Administration approved Truvada about 18 months ago. Still, many gay and bisexual men, and the transgendered, particularly outside urban cities, express surprise when they hear about Truvada.

Paul Lappin, a spokesman for The Project Quad-Cities, said nobody at his organization knows of a single person on it. The Project is located in a metropolitan area of about 500,000 people straddling the Mississippi River running through Iowa and Illinois.

A once daily pill to prevent HIV? And not many people know about it?

 

A powerful PrEP foe

The U.S. Food and Drug Administration approved Truvada after two large clinical trials demonstrated it works.

The National Institute of Health sponsored the first trial, known as iPrEx, in July 2007. It looked at 2,500 gay men and transgender women. It included participants from around the world, including the U.S., Brazil, Peru, Ecuador, Thailand South Africa.

The study showed Truvada worked in reducing infections by 43 percent, overall, when compared to those who received a placebo. Among those at extremely high risk, who reported having unprotected anal sex, Truvada reduced HIV transmission by 58 percent.

It is important to remember that these overall numbers include data from study participants who did not take the medication as directed. Repeated studies have shown that the higher the level of Truvada in the blood, the greater the effectiveness.

Some have argued against the use of PrEP, saying the drug could spawn dangerous, resistant strains of HIV. In the iPrEx study, two people developed drug resistance. However, they already had been infected with the virus and traditional testing before the study did not reveal antibodies. Still, this has raised an alarm. Little is known about the long-term use of the drug, but more studies are under way.

AIDS Healthcare Foundation (AHF), the largest provider of HIV care in the U.S., led the fight against FDA approval of Truvada. The concern was that it would result in people having riskier sex, but so far no studies have demonstrated that.

The FDA requires an HIV test before someone can be given Truvada. Doctors also have been advised to look for flu-like symptoms or anything that could reveal an early, undetectable infection.

But Michael Weinstein, president of AHF, said there is no way to know if doctors really are performing an HIV test before writing a Truvada script, or if they are requiring regular tests during treatment.

The FDA recommends quarterly HIV tests for someone on Truvada in case infection does occur.

Weinstein said he could get behind “any prevention strategy” that showed an effectiveness of 70 to 80 percent. He’d like to see PrEP come in the form of a patch under the skin or a monthly injection so it would have a longer half life for those who forget to take it.

“There are people saying this is an old fogy trying to push this outdated strategy on young gay men,” Weinstein said. “First of all, some things don’t go out of fashion, such as washing your hands to avoid infections in hospitals. Nothing has come out that’s better than that and it’s unlikely there ever will.”

Although studies have shown the drug to be well tolerated, it can lead to kidney problems. Those already suspected of having kidney problems must be closely monitored.

 

Meet Jeremy Dykes

From January 2011 to March 2013, about 1,800 prescriptions were written for PrEP, half of them for women. That number does not include thousands of other people across the U.S. who have taken PrEP in clinical trials. Even before FDA approval, Truvada could be prescribed off-label as PrEP.

That more gay men are not taking PrEP raises many questions. Is it too expensive? Not worthwhile?

HIV Prevention Drug Truvada as PrEP

Source: Dr. Joel Gallant

Dr. Joel Gallant, chairman of the HIV Medicine Association, believes that a lot of gay men just don’t know about the drug.

Jeremy Dykes, 39, lives in Nashville, Tenn. He began taking Truvada about a month ago. So far, he has not experienced any side effects, he said.

Dykes is not a fan of condoms. At the same time, he never thought the day of gay sex without a condom ever would be remotely sensible.

To that end, he enrolled in the HIV vaccine trial at Vanderbilt University. That’s how he learned of Truvada. Initially, when he checked with his insurance company, he learned the drug required “prior approval,” and he didn’t want to jump through hoops. In November, that policy changed, however.

Dykes immediately went to a doctor in Nashville who is well-known for being gay-friendly. Like many gay men, he otherwise was healthy and did not have primary care physician.

The doctor explained the potential side effects of the drug, performed tests for HIV and other STDs, and wrote a 90-day script for Truvada. “He put a ‘diagnosis’ of ‘high risk sexual behavior’ on my chart,” Dykes said.

Dykes gets tested for HIV eight times per year and is screened quarterly for kidney and bone-density issues, which can be side effects of Truvada.

 

Paying for Truvada

Truvada costs about $1,000 per month without insurance, Gallant said. While he mostly sees patients who already have HIV, he has prescribed it to some people as PrEP. None of them have had problems getting their private insurance companies to pay for the medicine, he said. “I’ve never even had to fill out a prior authorization form.”

Even some state Medicaid programs, such as New York, pay for PrEP with prior authorization. Gilead also offers assistance to people who need help paying for PrEP.

“This is a tempest in a teapot,” Weinstein said. “People are saying AHF killed PrEP and that’s why people don’t know about it. Doctors who provide care for gay men are not prescribing it and the gay men are not asking for it.”

If this were a hot new pill on the party circuit, surely many gay men would have heard of it 18 months after its rollout, he argued. “If this were a new recreational drug it would have spread through the grapevine instantly.”

 

Information

Although, not directly related to PrEP, Dr. Gallant disclosed he has previously performed research for Gilead.  Although imstilljosh.com doesn't believe there is a conflict of interest, we wanted readers to be informed.  For more detailed disclosures, click here.

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