Magic pill bottleneck: Effective HIV antiretroviral not getting to communities that need it most

A pill that can greatly reduce the risk of contracting or spreading HIV isn’t reaching the people who need it most.

Approved by the Federal Drug Administration in 2012, pre-exposure prophylaxis, or PrEP, refers to a once-a-day pill that could make HIV rates plummet if more widely distributed. If taken properly, PrEP reduces the risk of contracting HIV through intravenous drug use by more than 70 percent and lowers the chances of infection through unprotected sex by more than 90 percent. The latter figure is even better if PrEP is used in conjunction with condoms.

There’s just one issue: PrEP is hard to get.

The Cares Community Health medical clinic in Sacramento and Kaiser Permanente in Roseville are the only health care providers in the region that prescribe the medication, according to the website PrEP Locator. For the uninsured, the closest options are in the Bay Area.

That’s a big deal, as a 30-tablet bottle of Truvada, a brand name for the antiretroviral drug, can cost upward of $2,000 in Sacramento, according to the prescription drug website GoodRx.

Even with health insurance, there are hurdles to having it cover the cost of the medication, say advocates who work with at-risk populations. For PrEP to be covered by insurance, patients must fill out paperwork stating why they consider themselves high risk, and submit to ongoing monitoring and STD tests.

“That to me is a huge barrier,” said Kristen DiAngelo, who co-founded a local chapter of the Sex Workers Outreach Project.

Cares Community Health partner services coordinator Gustavo Trejo says that many people who come to his clinic seeking PrEP have to be turned away because their insurance requires them to see a specific doctor. This often forces them to return to doctors who are uneducated about the medication or unwilling to prescribe it, Trejo says. In other cases, doctors may not be familiar enough with how the drug works to prescribe it, tangling the patient in a web of referrals, appointments and tests.

DiAngelo has noticed that many doctors mistake PrEP for post-exposure prophylaxis, or PEP, a medication that can be taken within 72 hours of potential HIV exposure and has been likened to the morning-after pill.

Trejo also suggested that at-risk individuals can be afraid to broach the subject with their doctors.

Funding may be an issue, too. For instance, Golden Rule Services, another local health clinic, doesn’t offer PrEP. When asked why, Executive Director Clarmundo Sullivan said, “Funders are not excited about HIV prevention. Because strides have been made, people are living longer and infections are going down.”

Sullivan also emphasized that consistent use of condoms is still an effective means to prevent sexually transmitted diseases.

According to the California Department of Public Health, anywhere from 220,000 to 240,000 Californians were considered at high risk of contracting HIV in 2014, the last year for which figures were available. High-risk individuals include those who engage in ongoing sexual relationships with partners who are HIV positive or inject drugs; men who sleep with men; and people with multiple or high-risk sexual partners, such as sex workers.

The demographics hold true locally. Of the 3,469 HIV/AIDS cases in Sacramento County at the end of 2013, more than 66 percent involved men who have sex with other men. According to the state health department, approximately 4,900 gay and bisexual men in Sacramento County are at risk of contracting HIV.

For those who take it, PrEP can provide both protection and peace of mind.

“The freedom to live your life without fear is empowering,” said a 36-year-old Sacramento man who has taken PrEP for the past two years.

The man, whom SN&R is identifying as “Mike,” asked not to be named because of the potential stigma that taking the drug would bring to his partner. Mike is considered a high-risk candidate because he is gay. “There is an assumption that if you’re on PrEP you are somehow sexually promiscuous, when in reality it is the responsible choice to protect you and your partner,” he told SN&R.