Sex, Bottoming, and What You've Missed About PrEP

It's not often that a director at an esteemed non-profit is as straightforward and unabashed as Jim Pickett, Director of Prevention Advocacy and Gay Men’s Health, AIDS Foundation of Chicago. He's willing to talk frankly about sex, and PrEP's role in it.

But Pickett isn't just any non-profitter. He's spent a lifetime advocating for the health of gay and bi men, is currently chair of the International Rectal Microbicide Advocates, and is a staunch proponenet of any proven safer-sex prevention method, including PrEP. As fear culture has killed intimacy for many gay men, some argue that adding PrEP to the medicine cabinet may help change that. But Truvada won't be your only choice of PrEP down the line, says Pickett. We asked him explain why he and AFC supports PrEP, what might eventually replace Truvada, and what we still need to do if PrEP is ever really going to cut down on HIV transmission rates.

The Advocate: You say Truvada isn’t the only PrEP, or at least won’t be for long. Can you tell me more about that?
Jim Pickett: Truvada is the first version of PrEP; it most certainly won’t be the last. But I wouldn’t recommend people start holding their breath as we await new forms of PrEP. There is a significant amount of research that needs to happen before we have a new PrEP tool in the toolbox. This research, exploring a number of drugs and delivery systems, will take several years at a minimum.

Is that affecting how or why AFC advocates for PrEP use?
AFC has conducted research advocacy for new HIV prevention technologies for decades — we are beyond delighted to have something that is safe and works well come out the end of the research pipeline into the “real world.” We are thrilled to see that all the blood, sweat, and tears poured into the scientific endeavor and related advocacy come to fruition.  Our work will continue to support the research and development processes, as we believe strongly in having multiple options for people. And we are doing that with a much bigger spring in our step. Because we have one success, it is much easier to get people interested in the possibilities and engage them in the future of HIV prevention.

Do you have any idea what the biggest hope is for a second (or third) PrEP drug?
As chair of IRMA, I have a special place in my heart (and bottom) for a rectal microbicide. I think having a sexual lubricant, or rectal douche, that protects against HIV would be brilliant. Most of us who have anal sex use lubricants after all. And many of us who bottom use a douche to clean out beforehand. If we could tap into these products, and very common behaviors, we’d make rectal magic. There is currently a Phase II safety and acceptability study of a tenofovir-based rectal gel in the field with sites in Thailand, South Africa, Peru, and the United States. We should be hearing results from this trial in the first part of 2015, hopefully, and if all goes good, that product would move into a large scale Phase III efficacy trial.

Selzentry (or Marviroc, the generic name) is being tested, and while results aren’t available until mid-2015, tell me why there’s a belief this drug is better than Truvada?
I don’t know that anyone thinks it will be better per se. It has looked promising in earlier trials, and the fact that it is not used frequently for treatment makes it attractive for prevention [because there's fewer chance of resistance]. It also works against HIV in a different way from Truvada – which is also interesting. But the science — and clinical trial participants — will tell us whether the drug moves forward in the research pipeline or not.

Have we gotten reports on Marviroc that were more discouraging than hoped?
I think the jury is out!

Is anyone recommending that gay or bi men with concerns about Truvada as PrEP wait until one of these other drugs is available?
I have heard people say, “Hold on, we’ll have new PrEP drugs in a couple of years.” To which I say, “No we won't!” We are going to have Truvada, on it’s own, for several years at a minimum before something else potentially joins it. If folks are not comfortable with Truvada as PrEP, they can of course use other means of prevention — TasP, male/female condoms, sero-adaptation — until something else comes along. For some perspective: of 10,000 compounds that get tested in the lab, five make it to human trials and one makes it to market. So, oral Maraviroc, a rectal gel, and a couple of long-term injectables have made it out of the lab and are in human trials. This is fantastic, exciting, promising, and worth our attention. But just because a product makes it to Phase II, or a Phase III efficacy trial, is no guarantee we will have something in the market soon thereafter.  And even if something is shown to be safe, acceptable, and effective in trials – we then have approval processes to undergo. The process is long. You need to be able to see the light at the end of the tunnel, be patient, be dogged, and not lose focus. That light might be a distant flicker for a long time. Science is slow and steady for good reason, and is not for the impatient.

What else do should we know about PrEP?
We have a lot of work to do with Truvada as PrEP to improve access for the people in our country hardest hit by the HIV epidemic.  We have serious drug cost issues. We have insurance plans with high co-pays and deductibles. We have uninformed and misinformed health care providers and communities. We have people still freaking out over non-condom safer sex options. We have a patchwork health care system that doesn’t serve all of us very well much of the time. The better we do with Truvada as PrEP in terms of roll out, the better positioned we will be to realize the promise of new versions of PrEP that pop out that pipeline in the future. We must do our best now — right now, this very second. We do not have the luxury of waiting for the next best thing. As we know, there will always be a next best thing, right? The grass is always greener, the next iPhone is always better than the one we have in our hands. But PrEP science isn’t as speedy as Apple. We have to work with the thing we have in front of us right now, and stay engaged with what is coming. A bit more complex than walking and chewing gum, but doable!