Supes OK PrEP Funding

The San Francisco Board of Supervisors Tuesday approved a supplemental budget request to help people access pre-exposure prophylaxis, or PrEP, for prevention of HIV infection.

The measure, introduced by gay District 9 Supervisor David Campos in September, allocates $301,600 to hire "navigators," counselors who will help people obtain PrEP through existing channels such as private insurance, Medi-Cal, or Gilead Science's patient assistance programs. The funds will not directly pay for PrEP medications.

"PrEP has the potential to save hundreds or thousands of lives," said Campos. "San Francisco must continue to take a leadership role in the battle against HIV/AIDS."

The Food and Drug Administration approved Gilead Sciences' Truvada (tenofovir plus emtricitabine) for PrEP in July 2012. This past May the Centers for Disease Control and Prevention recommended that people at substantial risk should consider PrEP to prevent HIV infection, and in July the World Health Organization recommended PrEP as an option for at-risk gay men.

The board vote was 10-1, with Supervisor Katy Tang voting no.

In an email, Tang said that while she is supportive of HIV prevention and outreach efforts she generally does not support supplemental appropriations, which take place outside of the normal budget process.

The Department of Public Health will now flesh out the details of the navigator plan and funding will go through a request for proposals or RFP process.

"Today, we've taken a bold first step in expanding access to PrEP in San Francisco," Campos said in response to the vote. "By embracing this measure and committing to do more, San Francisco has heightened the dialogue on PrEP - working to reduce the stigma and promoting a path to no new infections."

Also on Tuesday, gay District 8 Supervisor Scott Wiener called for a hearing on the status of San Francisco's "Getting to Zero" effort, a collaboration among public health agencies, nonprofit healthcare providers, and advocates.

"San Francisco has made huge strides reducing new HIV infections, quickly connecting people to treatment, suppressing viral loads, and reducing HIV-related deaths," Wiener said. "Now is the time to put the final nail in HIV's coffin in San Francisco by ending this epidemic once and for all."

The Getting to Zero Consortium aims to reduce new HIV infections and HIV-related deaths by 90 percent by 2020, using a three-prong strategy that includes expanded access to PrEP, rapid access to antiretroviral therapy, and retention of HIV-positive people in care.

Tang said that she is supportive of Getting to Zero.

"I look forward to having a more comprehensive dialogue with DPH to put together a more comprehensive funding plan during the regular budget process to ensure that San Francisco remains a leader in HIV prevention, outreach, treatment, and education efforts," Tang said, referring to the health department.

Campos explained that after conversations with DPH, community members, and budget and legislative analysts, he reduced his initial request of $801,600 from the city's general fund reserve by half a million dollars. Analyst Harvey Rose said this would allow the city to hire six or eight PrEP navigators, rather than the 12 previously envisioned.

Budget Committee Hearing

Members of the board's Budget and Finance Committee considered Campos's PrEP request at their October 22 meeting. DPH officials, researchers, representative of local AIDS service organizations, and members of the public offered testimony on the measure.

"Numerous studies have shown that daily use of PrEP can nearly eliminate the risk of contracting HIV," according to Campos. "Because [new infection] rates are steady, this is a tool to reach those who aren't using existing prevention methods."

In 2013 there were 359 new HIV infections in San Francisco, according to DPH figures. Nationwide, incidence has remained stable for several years at around 50,000 infections annually.

"After more than three decades of prevention efforts, although we've made great strides in San Francisco, until there no more new infections we still have work to do," concurred Wiener, who made headlines last month when he publicly disclosed his own PrEP use.

Speaking at the budget hearing, Dr. Robert Grant of the UCSF Gladstone Institutes and principle investigator for the pivotal iPrEx trial said that, "PrEP works when you take it. PrEP stops HIV and that benefit is enough, but it's not the only benefit - PrEP sends a message to people that their lives matter."

In iPrEx, Truvada PrEP reduced the risk of HIV infection for gay and bisexual men by 44 percent overall compared to a placebo, rising to 92 percent among participants who took Truvada every day as directed. An open-label extension phase of the study saw no new infections among men whose blood drug levels indicated they took the drug at least four times per week.

More recently, the U.K. PROUD trial, also studying daily PrEP for gay men, halted its placebo arm after early results showed a reduction in new HIV infections in the Truvada arm. Similarly, the French IPERGAY study, looking at "on demand" PrEP taken before and after sex, also stopped its placebo arm this week after seeing unexpectedly high effectiveness in the Truvada arm. The first data from the two trials are expected to be presented next year.

Yet despite the evidence in its favor, Grant estimated that fewer than 1,000 people in San Francisco are taking PrEP.

Lack of access remains the main barrier to wider PrEP use, several speakers testified. The cost of Truvada - at approximately $1,400 per month - a shortage of knowledgeable providers, and inadequate outreach to communities that need it most all contribute to limited access.

The nearly two-dozen speakers at the hearing include people living with HIV, HIV-negative people who were using or wished to use PrEP, and representatives from agencies serving people living with or at risk for HIV. Several people of color stressed the need for culturally competent navigators and PrEP information in multiple languages.

"For first time in my adult life, I have don't have a cloud of fear hanging over my head," said Paul Langley. "PrEP has given me peace of mind."

"I've been an HIV provider for almost 20 years, and PrEP is the first thing I've seen that I actually think could have an impact on preventing new cases of HIV," added Dr. Dawn Harbatkin, medical director for Lyon Martin Health Services.

Budget and Finance Committee members Mark Farrell, Eric Mar, and John Avalos - all of whom are co-sponsors of Campos's measure, along with Wiener and Supervisor Jane Kim - voted to send the request to the full board.