From a Woman's Perspective: What does PrEP Mean to the Black Community?
By Tina B. Henderson, PhD
I was invited by Mr. Tony Wafford to write this response about PrEP (pre-exposure prophylaxis) from a woman's perspective. I gave much thought as to how to respond eloquently in the amount of words specified because there is so much to know and understand about this topic. Thus, I decided to respond as to what does PrEP mean as a researcher and then as an African-American female.
PrEP involves taking daily medicine in order to prevent HIV-negative individuals from contracting HIV through sex. It is an HIV prevention strategy in which one or more antiretroviral drugs (ARVs) are taken consistently by an individual prior to or during potential HIV exposure, with the goal of reducing the likelihood of HIV infection. This does not mean that someone should not use condoms because they are on the medication, but that the medication is taken in conjunction with condom use and regular HIV testing. This prevention strategy isn't so much about letting folks get their freak on as it is providing people with a way to minimize their risk.
With the increased number of those, in particular African Americans, who are becoming HIV-infected, PrEP is one of the biomedical strategies now available to address reducing the HIV epidemic. PrEP is not a drug itself, but rather it is a strategy and the focus of this current conversation is on the drug, Truvada or as Tony Wafford has fondly deemed it "the Wonder Drug." Gilead Sciences, Inc. is the pharmaceutical company that produces Truvada. The early studies (iPrEX studies, which were mostly done outside the US and with men who have sex with men (MSM)) have shown that if used in conjunction with condoms, the chances of contracting HIV is reduced by 44 to 75%. It is important to point out that in the studies the strategy included prevention counseling and regular HIV testing. Reasons vary why some participants had better outcomes than others, ranging from taking their medication as prescribed, limiting the number of partners, and decreasing the numbers of high-risk behaviors.
The rates of undiagnosed HIV infection are very high and that coupled with poorer treatment outcomes for Black folks living with HIV contribute to the ongoing epidemic in the Black community. If an individual chooses to use PrEP as part of their strategy to reduce their risk for HIV, then that by its very essence is personal responsibility. Should someone choose to spend $1400 per month, it is more cost efficient than the over $600,000 for treatment over a lifetime.
The point was made about the bottom line is whether someone wants to spend an exorbitant amount of money (the cost is $1472.09 per month, which some health insurance covers a good portion of the cost) is worth the effort or if it makes more sense to spend $1.99 at the corner drug store to buy condoms. If it were as simple for folks to understand they can reduce their risk substantially by just putting on a condom, it would make my life a whole lot simpler. As someone who has been in the HIV/AIDS field for almost 20 years, "Lord help me Jesus," it would make my life that much easier if folks would just wear a condom and get tested. But the rates of HIV in the Black Community speaks to differ; we are NOT practicing safe sex nor using condoms as we should. No group is having more sex than the other group, but rather the HIV sero prevalence rates are higher among certain groups. With such rates, there is a increased probability someone can be exposed to HIV simply because they are having sex with someone who is Black, couple with the fact that the high number of folks who don't know their HIV status increases one's potential exposure to HIV. As of 2009, the rates of new HIV cases among African Americans (AA) are over 40%, among AA MSM are 73% and among AA women over 80%. For women heterosexual transmission is the most common mode of transmission.
Is PrEP for everyone? No, it is not. There are specific populations that may find using this strategy complimentary to their HIV prevention practices and safer than trying to get their partner to use a condom, for example, men who engage in high-risk behaviors or women in violent relationships. In a recent report published by UCSF, physical abuse, adult and childhood trauma are driving the HIV epidemic among women.
What does PrEP mean for women? As far as women (specifically in the US), there are no studies to date that have included US women, however the current Health Prevention Trials Network (HPTN 069, ISIS Study) protocol will be developed in the near future (Fall 2012/ Winter 2013) and will include women. Researchers continue to develop the use of microbicides, which comes in gel or foam form, as an appropriate strategy for women to reduce contracting HIV. Women can use micorbicides to help prevent contracting HIV in control and violent driven situations.
The ISIS study was one of the few studies conducted in the US that had a large African American female participation. It was a well developed study that not only provided the US with how poorly women have been tested and treated, but it also highlighted strategies that must be incorporated when doing community outreach and education with women.
What stands out in responses in these PrEP conversations are: Test, treat, linkage and support, which is a comprehensive biomedical model. Something that was highlighted is personal and social responsibility. While it is a fact that not every approach will work for everybody, everyone should be concerned about how to best protect him or herself. As people in the HIV prevention field, our primary concern should be how we can meet people where they are so that we can end this epidemic. Choosing to reduce your chances of HIV contraction is taking responsibility.
There are still many questions about what PrEP means to women and to the Black community.
o What are the implications for reproductive health for women who may want to use PrEP?
o What are all of the interactions with other medications?
o Where is Gilead and the FDA at in response to approval to use Truvada as prevention in the general community)?
o Who is the research community communicating with in the Black Community and how can you as concerned citizens join with them?
o What are the opportunities to get involved by joining a Community Advisory Board so that you can review protocols in the development stage and ensure that the voice of the community is heard?
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