How PrEP Is Being Blocked By Bureaucracy

After months of petitioning from HIV/AIDS advocates, officials with Los Angeles County's Division of HIV and STD Programs (DHSP) presented a county-wide implementation plan for PrEP during a mid-March public meeting.

The announcement came after activists, including Craig Thompson, CEO of AIDS Project Los Angeles, charged the county with delaying the creation of a campaign designed to educate HIV-negative gay and bisexual men about PrEP and providing them with access to medication. Thompson says it was a complicated political issue for county officials and that "like most bureaucracies, they don't want to have to deal with it."

"There's enough conversations now where people are starting to get PrEP...and the interest is growing very rapidly," Thompson says. "We have encouraged [Los Angeles] County to take that first step and fund a PrEP navigation and education program of some type."

Data released by the Centers for Disease Control and Prevention in 2013 listed Los Angeles within the 20 U.S. cities with the highest HIV infection rates. Last year, the CDC issued new guidelines recommending daily PrEP use among HIV-negative men who have sex with men who are "at substantial risk for HIV." The Food and Drug Administration approved Truvada, an antiretroviral drug already used to treat existing HIV infections, for PrEP in the summer of 2012.

Thompson acknowledged that little was known about PrEP a few years ago but highlighted emerging discussions surrounding the treatment, specifically within Los Angeles County. Last fall APLA launched a PrEP program that educates eligible patients and offers them access to Truvada.

But Thompson said opponents of PrEP are far more vocal in Los Angeles County than in other regions -- specifically the Los Angeles-based AIDS Healthcare Foundation, which touts itself as the "largest provider of HIV/AIDS medical care in the U.S." AHF president Michael Weinstein has previously referred to Truvada as a "party drug," implying that its use in certain situations could potentially leave gay men susceptible to infection. Other critics argue that it will lead to a rise in promiscuity and unsafe sex among MSM.

Los Angeles County's public health department stressed that AHF's critiques don't deter the county or the department "from pursuing sound HIV prevention policy supported by research, science, data, evidence, and the [FDA] and [CDC]." But Thompson said the AIDS Healthcare Foundation has been "pretty persistent in its attempts to slow the process around the county developing a PrEP program." He called the plateaued efforts "extraordinarily frustrating and bewildering," noting that the funds to implement a countywide program are already available thanks to the Ryan White HIV/AIDS Program and the Affordable Care Act.

Thompson praised both New York City and San Francisco for their respective efforts in providing proper PrEP education to gay and bisexual men.

Thompson credited San Francisco supervisor Scott Wiener for demystifying PrEP by acknowledging his own use of Truvada in an op-ed for The Huffington Post. And in New York, Governor Andrew Cuomo has included PrEP in his highly regarded plan to reduce new HIV infections in the state by 2020.

Los Angeles County's public health department says it anticipates supporting a range of activities to increase PrEP awareness, including training community agencies, requiring testing providers to discuss PrEP with their clients, creating a PrEP provider directory, and maintaining a PrEP section on both its Web site and the Division of HIV and STD Programs' page. Health officials said during their mid-March public meeting that the department hopes to implement PrEP in public health clinics by this summer, with the county likely paying for most PrEP-related costs.

Thompson said APLA will continue to target black and Latino gay and bisexual men in low-income areas with its PrEP program.

"PrEP is going to be one of the activities that's going to take years to roll out--this could be a lifetime intervention," Thompson says. "We really need to be taking the initial steps as soon as possible because we're losing and have lost really valuable time."