Advances in HIV/AIDS Prevention

HIV/AIDS is recognized as a chronic disease, and while treatments have improved, prevention of the disease remains a critical public health issue. In 2012, a medication was approved for use by those deemed “high risk” of contracting HIV/AIDS. The drug, Truvada, was one of the first widely used pre-exposure prophylaxis (PrEP), and it has become the preferred drug treatment of HIV/AIDS physicians.

The story of Truvada began in 2007 with an HIV/AIDS clinical trial on high-risk males at 11 study sites including two in the United States. The goal of these trials was to test the effectiveness of pre-exposure prophylaxis (PrEP). In 2010, findings from this study were presented in a New England Journal of Medicine article that concluded that PrEP could reduce new HIV infections by approximately 90 percent in subjects who adhered to their prescribed regimen. These results prompted the Centers for Disease Control (CDC) to recommend that men who have a high risk of contracting HIV take a daily pill. In July 2012, the FDA approved Truvada (emtricitabine/tenofovir disoproxil fumarate) as a prevention method. In June 2013, the CDC revised its recommendation to include PrEP as one among various options presented to high-risk men.

There has been some controversy regarding the use of Truvada in HIV-negative men to prevent infection. An article on the AIDS Healthcare Foundation website suggested that the lack of a concomitant HIV testing requirement by the FDA could result in untested HIV-positive men taking Truvada for PrEP and developing anti-retroviral medication resistance (or inadvertently promoting increased transmission in the general population). Meanwhile, in an article entitled, “HIV Controversy: A Pill for Prevention” (2012), Dr. Kenneth Mayer of the Fenway Institute was quoted expressing positive sentiments about the use of Truvada for PrEP in reducing HIV transmission.

The relationship of PrEP use of Truvada to future anti-retroviral resistance remains unknown. There are other concerns about adherence, as the pill must be taken on a strict regimen to be effective. Since medication adherence is an issue for IV drug users and for many in underdeveloped nations — where obtaining anti-retroviral medication can be particularly difficult — the potential for the development of drug resistance remains a possibility. Additionally, use of Truvada has been linked to kidney problems.

Another concern, as with many HIV/AIDS medications, is cost. At a cost of around $900/month, this pharmaceutical agent (made by Gilead Sciences, Inc.) is expensive and not always fully covered by insurance. The Affordable Care Act may help change that, however. In a recent article, the CDC reports that only 17 percent of people in the United States living with HIV/AIDS have private insurance coverage. With the enactment of the Affordable Care Act, patients will have better access to services and medications. The new legislation broadens Medicaid eligibility, closes the “donut hole” of the Medicare Part D prescription drug benefit (thereby covering more of the costs of HIV/AIDS medication for Medicare-insured individuals), and eliminates annual reimbursement caps on insurance coverage. Additionally, preventive services (“A” or “B” grade) must be covered by health insurance companies at no cost; HIV testing is one of the covered preventive services.

Scientific research remains critical for communities and individuals around the world. The HIV infection rate in Washington, D.C., for example, is more than 3 percent of the city’s population, which is higher than rates in many developing nations. George Washington University’s School of Public Health and Health Services is working to reduce infection rates through the District of Columbia Developmental Center for AIDS Research (DC D-CFAR). With DC D-CFAR, GW students have a chance to participate in substantive research and work with professors who are pioneers in the field. With more than $40 million in grants in 2011–2012, GW is working to improve clinical knowledge and promote health policy scholarship for HIV/AIDS prevention.

As HIV-infected individuals in the United States live to an older age, new problems are emerging in their physical and emotional care. Vision loss, high cholesterol and cardiac problems are frequent complications that are related to long-term anti-retroviral medication use as well as the HIV infection itself. Although chronic management has enabled the capacity for long-term survival, the public health issue of HIV prevention remains critical to controlling the epidemic. Whether Truvada will continue to be the drug of choice to aid in the prevention of HIV/AIDS or whether another drug will take its place remains unknown, but it’s clear that PrEP may be the answer to helping us see an HIV/AIDS-free generation.