With 400-plus new cases of HIV last year and evidence that PrEP is so effective, why isn’t Truvada freely available in Ireland, asks Stephen Meyler?

Although HIV and Aids have pretty much dropped off the radar for most gay men (until they get infected, that is), treatment has been changing so radically that it’s quite possible it might eventually go away, despite the resumption/continuation of business as usual for a significant minority when it comes to bareback sex or needle sharing. There were more than 400 newly detected cases of HIV here last year, the biggest number since before the recession, and half of those were among men who have sex with men (MSMs).

The sea-change for the disease makes the headlines in occasional science-y colour pieces or when celebrities like Charlie Sheen reveal they drank goat’s blood in Mexico rather than take evil Western medication. Funnily enough, Sheen’s HIV became re-detectable after the Mexican blood regimen, but presumably he’s now taking something that actually works.

Most people are aware that the miracle drugs developed from the 1990s on mean the majority of people with HIV in rich countries never develop Aids, and their HIV counts are so low (or undetectable) that they may not even be all that infectious any more. They are most likely to give someone else HIV when they are engaging in risk behaviour before they know they are positive, which is typically a period of several to many months in cities with active HIV awareness campaigns.

Significant Shame

Here, though, there’s still such significant shame about HIV that we prefer not to think about it, so many of the 400-plus new cases in 2015 were late presenters, who had HIV for so long before testing that they were at risk of going ‘full-blown’ or indeed, already had. Nine people died of Aids-related complications last year.

For those who have been tested and started on anti-retrovirals (ARVs), the drugs work so well, that the focus for these people has shifted from developing Aids to the long-term effects of taking ARVs. Add PEP to the mix and it might seem that the outlook for HIV treatment has never looked better.

The pool of unaware HIV positive people is one place HIV continues to hide; the other is of course, in lymph nodes. Last year, researchers got very excited about this, as they thought they might be able to get to HIV there too, meaning it may soon have nowhere left to hide in the human body from which to re-enter the bloodstream (and become infectious again), if the person stops taking their meds.

For a lot of people, though, the biggest change with HIV in years is PrEP. It’s currently not part of the HIV treatment system in Ireland (although it is occasionally given on a case-by-case basis, for example in a serodiscordant couple, i.e. where one partner is HIV positive, and the other negative).

It’s been all the rage in the US for a number of years now (as Truvada, which sounds like a lifestyle brand you want to get on board with!), and when it’s used properly, pretty much shuts down HIV infection.

A Judgemental Turn

Arguments against PrEP often take a judgmental turn – you can’t trust those pesky gays to behave responsibly if you give them a get out of Aids jail card. The PROUD study in the UK tried to tackle this belief (which has some traction among gays too). It split a group of gay men in two and gave half PrEP for a year and the other half nothing, before starting that second group on PrEP at the end of the year. The crucial thing, though, (and which goes against the usual randomised, anonymous way of doing such things), was that the researchers told the men if they were getting PrEP or not, and told them to go on like they normally would – using or not using condoms, having or not having anal sex, PEP, etc. A year later, they looked at the numbers: PrEP reduced the rate of new HIV infections by 86 percent – not unexpectedly – but the incidence of other STIs was the same in both groups. So PROUD suggests that PrEPpies aren’t immediately throwing caution to the wind when they get their Truvada.

So with 400-plus new cases of HIV last year and evidence that PrEP is so effective, why isn’t it freely available here? Unfortunately, one factor is likely to be cost. A month’s supply of Truvada costs more than €500 in the UK, so God only knows how much the HSE would be charged for it here. (A little known fact is how much power we mere 4.5 million Irish people have over global pharmaceutical companies with their 9 billion customers. The reason, you see, we continue to pay the highest drug prices in Europe is because if we didn’t, they would immediately close all their very expensively built drug plants and move to Poland or wherever.)

However, the economics stack up in favour of PrEP: the average lifetime cost of treating HIV is €460,000-plus, so PrEP seems like a decidedly cheap option. Soon it will be even more so, as a generic version of Truvada will become legal in 2017.