PrEP (HIV infection prevention) therapy ... is it available in Thailand?

[mania]

The only other downside I can see to this...

I say other because no matter what this is a strong drug & has its risks.

But the other downside. When the lady I knew was put on AR drugs

she was told hopefully the first one works as some are resistant to some

& there are not many options. Luckily she was ok

The second thing was the importance of not stopping because if stopped

you may become resistant to it if/when restarted...Not unlike many antibiotics which

no longer work for some if not used properly

So as an insurance policy folks may use this PrEP but then when perhaps economically not feasible

(this is for life) or they decide they are no longer at risk may stop...Which is fine but what if later they do

in fact contract HIV & the drug no longer has its effect for them?

So for anyone considering this path I would only hope they realize it too is a type of life commitment

in some ways once started. They must be very committed to it.

As to why it is not as pushed in Thailand the above concerns could be a reason?

I mean looking at even things like penicillin & how it is used in the west compared to here.

Could just be a different way of looking at the use of drugs in general. I don't know & am just guessing here

Edited October 27, 2014 by mania

[mommysboy]

Having had a good old think about this I think it is a bad idea. It's essentially giving a strong drug devised for the treatment of a disease to people who don't even have it, even if it is thought they are likely to succumb at some point. These drugs may have side effects. A person will have to take them for the duration of their natural life so why start before they are even needed.

All you can reasonably do is educate people in to the folly of unprotected sex with an infected partner. And would they faithfully take the medicine anyway ?, after all they have thus far shown little regard for their own welfare.

Perhaps there might be some merit for sero discordant couples wishing to start a family, this is a possible justification for a temporary course.

[Jingthing]

I don't think there is a blanket right or wrong answer on whether it is a good idea to do PrEP or not. I think it makes sense for some people, and not worth it for others. As the WHO advises, for people in the MSM high risk group, it should be CONSIDERED. But I do think people are probably exaggerating the specific side effects for PrEP. So far what I've read (which I admit isn't exhaustive) is that most people can deal with it without severe side effects and the more noticeable side effects are felt in the early stage adjustment period and then GO AWAY.

Edited October 28, 2014 by Jingthing

[Jingthing]

(Note: I am still not sure if this topic belongs on this forum or the gay forum. However, I have decided to not open a new PrEP topic on the gay forum (as that would be TWO threads about basically the same thing) and just let the wonderful management team here decide whether to keep it here on the health forum or move it to the gay forum. Either way, fine with me.)

OK, I found an interesting THAI connection to the PrEP story which definitely is not going away, but is clearly going to get bigger and bigger, even if not yet widely being considered in Thailand (at least that is still my assumption at the state of PrEP in Thailand).

This is about the current method of PrEP (which is Truvada or generic) will probably be later developed into other medical ways of delivering PrEP. In this case, active research is being partly done about that in ... you guessed it ... Thailand.

http://www.advocate.com/31-days-prep/2014/10/29/wait-truvada-isnt-only-prep

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.

This health activist argues AGAINST not waiting for "something better" for people in high risk groups though.

To wit, from another link:

http://www.advocate.com/31-days-prep/2014/10/29/study-shows-demand-prep-drastically-reduce-hiv-infection

Although the U.S. Food and Drug Administration approved Truvada for use in PrEP over two years ago, PrEP has only recently begun to receive widespread acknowledgement among public figures and organizations for its lifesaving potential. In the past few months, the Centers for Disease Control and Prevention, World Health Organization, Gov. Andrew Cuomo of New York, and the Human Rights Campaign have all come forward in support of PrEP.

I read somewhere else (sorry no link handy) that high risk MSM people using a combination of condoms and PrEP have 99 percent effectiveness against becoming infected. I don't know how that compares to people who are just using condoms only, but surely better protection.

Edited October 30, 2014 by Jingthing

[steveromagnino]

I volunteer with HIV foundations, so this is a subject I know a little about from the research and institution side.

PrEP is typically a 2 or 3 cocktail pill (2 in the case of Truvada). Truvada is a single pill comprising the 2 best (meaning lowest side effect) drugs in Atripla (Atripla is a combination of 3 meds in 1 pill). It is usually quite well handled by most people. Truvada and Atripla are already available here, but I am unsure whether it is free or paid (I do not get involved on that side).

Note some ingredients in the first line treatments is no picnic, the Sustiva in Atripla is known to cause a huge rash temporarily for many, hangover type symptoms, sleep disorder, nervous system and depression issues....some of the cheaper crappier treatments commonly given out for free in Thailand give lipodystrophy (basically deformation of the normal body shape with buffalo hump and stomach and throat area fat accumulation as well as weight loss and fat loss in the legs and limbs. Having spent time at HIV hospices (before the days of treatment) and more recently at orphanages and functions, I can sometimes pick the HIV+ people by the oddities in their body shape. And that's ignoring anaemia, cholesterol issues and other longer term health problems. So if doing PrEP it would seem choosing the right cocktail is critical to ensuring compliance and minimal side effects.

Truvada incidentally has been known to cause some of the above effects, as well as kidney, liver and other issues. So it's not like popping a vitamin C. And it is considered one of the easiest lowest side effect options.

Obviously, once infected, treatment as a prevention (and as a treatment) is better than no treatment for all except elite controllers who are exceptionally rare in Thailand due to the A/E subtype. therefore the lowest hanging fruit is finding everyone who is infected, and putting them on treatment that reduces VL to <50 (undetectable) - this concept of treatment as prevention is not a replacement for people using their brain, but let's face it, people are pretty dumb, so it's a major step in the right direction to reduce the odds of transmission, which are strongly related to level of VL.

Which comes to your question: So is treatment better than no treatment for high risk pre exposure?

it probably is, but with significant caveats and cost implications.

Jingthing you are not entirely wrong to think Thailand is 'behind' or that this is not on the agenda. It is being discussed. However, we are living in a country where many infected do not know, many infected are either not treated or being treated sporadically (one of the most dangerous aspects of HIV is poor adherence to the regime), and there are high risk groups. The subtype here A/E is fairly virulent also with a shorter time until an AIDS diagnosis than subtypes in the west.

A rural 8 year old kid I knew back in the early 2000s, was very sick (when I knew him) went on treatment, got better (which I knew), then his grand parents (his parents who infected him were already dead) saw he got better, took him off the treatment and he got worse and ended up dying. So, a fraction of the money spent on PrEP could instead be likely better spent teaching people like this kid's parents. And a substantial amount spent on treating the infected to get their VLs to as low as possible.

However.... the idea of putting large proportions of the public on a treatment that relies on complete adherence to work and relies on dedicating a substantial portion of budget to preventative treatment when treatment of existing infections is still not quite where it should be. The country could likely struggle to pay for a massive PrEP program. With subsidised healthcare, this could easily be costing the state 5,000b per person per month indefinitely X up to 500,000 people; that is an ENORMOUS budget to sustain.

If introduced, worldwide we can already see the increase in drug resistant HIV (20% of new infections show resistance to at least 1 first line drug) partly due to the evolution of the virus and partly due potentially to poor adherence to the cocktail.

And that's the rub. For PrEP to work, it relies on 100% adherence at time of exposure, clear identification of patients who might be infected prior to starting treatment, and the ability to recognise and deal with patients who get infected anyhow and removing them from PrEP and putting them on proper HIV treatment. And even then it is not always going to work, just as condoms and other measures don't work 100%.

Highest risk groups, not yet infected, may struggle with the idea of being able to or having to comply 100%. Once people start missing doses from getting high, drunk or not caring, then a low level of medication in the blood gives the virus a door to become resistant. Studies claim that there is no significant risk of resistance on PrEP but I look at the n<100 relevant cases and I would question the stats here to project such a strong conclusion: http://www.aidsmap.com/No-significant-risk-of-resistance-if-HIV-infection-occurs-during-use-of-iTruvadai-PrEP/page/2849061/

If an infected drug resistant person is still engaged in high risk behaviours they may potentially start spreading a truvada resistant strain. Far from ideal.

At any given time it is a simple statement of fact that there are MSM, prostitutes and drug users in Thailand engaging in risky behaviours knowing they are infected and either not being treated or being completely inconsistent in their treatment. PrEP can solve some of the risk on the recipient side, but it is not the whole story, nor the 'lowest hanging fruit'; that is clearly treating the people infected now and getting the viral load level down to undetectable across the board.

Hans Rosling does a good job of showing the general nature of infection BTW:

http://www.youtube.com/watch?v=3qRtDnsnSwk

It's an interesting subject, without a clear answer one way or the other. I'd prefer effective education ahead of compulsory PrEP, partly because I am a realist, and partly because I suspect the highest risk groups will not be ideal candidates because the factors that make them the highest risk are the willingness to engage in activities that are high risk (obviously); therefore I question whether they would adher to something that lowers the risk. On the other hand voluntary PrEP for those wanting to take action (opt in) is already available now at a cost, for those who are irrational enough to take high risks but want to do something about reducing the biggest consequence. Note that PrEP does nothing to stop the spread of treatment resistant hep, StDs etc etc.

Edited October 31, 2014 by steveromagnino

[japsportscarmad]

In Thailand the "high risk" population is not just the gay community, its is the ALL Thai population. Most, and in ALL social classes, do not have any knowledge and concerns about HIV infection.. To have sex with ANY Thai without protection, is playing with death.

Bit of a silly post Sir????

what about a thai virgin????

Indeed very discriminatory suggesting Thailand is any greater risk, horrible. Edited November 6, 2014 by japsportscarmad

[Jingthing]

Each country would have it's own level of risk based on infection rates... and of course you need to factor in the demographic of the population within any country you are talking about. If you're considering have unprotected MSM anal sex in Thailand, you're talking very high risk.

[japsportscarmad]

Don't worry about me I won't be doing that.

What's MsM?

Does HIV bother you?

Edited November 6, 2014 by japsportscarmad

[Jingthing]

Don't worry about me I won't be doing that.

What's MsM?

Does HIV bother you?

MSM means Men having sex with men, because globally a large percentage of male to male sex is done by people who don't identify as gay. So it's a clinical term.

HIV bothers me, yes, because I think too many people are STILL getting infected and it has become more preventable so that's horrible, and also it's personal to me because the majority of friends I had in my 20s never saw 30 so I had kind of a Lost Generation experience and was kind of surprised to be a survivor of it. (I was kind of at Ground Zero, San Francisco in the 80s, people mostly young were dying like flies). I am negative myself.

Cheers.

Edited November 6, 2014 by Jingthing

[japsportscarmad]

Don't worry about me I won't be doing that.

What's MsM?

Does HIV bother you?

MSM means Men having sex with men, because globally a large percentage of male to male sex is done by people who don't identify as gay. So it's a clinical term.

HIV bothers me, yes, because I think too many people are STILL getting infected and it has become more preventable so that's horrible, and also it's personal to me because the majority of friends I had in my 20s never saw 30 so I had kind of a Lost Generation experience and was kind of surprised to be a survivor of it. I am negative myself.

Cheers.

That's sad loosing friends like that so your in your 50s? But good your negative.

I learn something every day so men on men sex happens with straight guys? Then they're ever gay or bi?

If it any consolation I lost most of my friends through the army and doing stupid stuff as well fast cars and bikes mainly but not HIV. In fact a few weeks ago we were looking at a student class photo and 4 we didn't know about but out of 36 we were the last 5 which is a bit scary. So 27!were confirmed dead.

I believe my generation that no one thinks about HIV, a mate of mine in Manchester caught it of some woman and he's in his 50s and she was in her 60s neither of them thought of any protection at their age was required, they seem healthy but on those retro viral drugs? which have loads of side effects I was glad he felt he could tell me.

Edited November 6, 2014 by japsportscarmad

[Jingthing]

Back to PrEP, this is a really interesting new development.

As I've expressed I don't think reliance on condoms is good enough for various reasons:

1. Lack of 100 percent compliance

2. Sex is messy. Stuff happens.

3. Condoms and being romantic/spontaneous don't mix so well. Sometimes the latter wins the moment.

4. Condoms often break

5. Preejaculate ... happens BEFORE condoms put on

6. Often condoms put on improperly.

7. Condoms fall off

etc.

We're human ... stuff spills.

There have been objections here to daily PrEP pills. Understood. But check this out!

http://www.hivplusmag.com/research/2014/11/05/prep-demand-study-halted-because-it-was-so-successful

Even more intriguing was the IPERGAY regimen design. Rather than the one-pill-a-day dosing used in previous trials, subjects were given a "PrEP on demand" dosage schedule. The regimen calls for two pills at least two hours prior to sexual activity, and then one pill for each of the next two days. Previous trials have also shown efficacy with as few as four pills per week, but the "Prep on demand" model appears to focus the medication around actual sexual activity, when the body may need it most. (See graphic below.)

Initial study proven very effective.

This is potentially significant because many people are not sexually active all the time but occasionally active. This way they can use PrEP and not need to be on the pills all the time. ONLY when needed ...

[japsportscarmad]

It's interesting stuff but condoms protect about other nasty stuff as well.

[Jingthing]

It's interesting stuff but condoms protect about other nasty stuff as well.

Correct, but be clear people are being told to use condoms AND PrEP. Just condoms provides pretty good protection (but consider the flaws mentioned) but condoms plus PrEP and evidence shows 99 percent protection. It is clear to me that the concept of PrEP in some form (even if it's very different like a special lubricant) is the wave of the future and condoms alone are going to start to be seen as NOT GOOD ENOUGH.

[japsportscarmad]

Condoms are crap I have a spinal injury to my neck it snapped (don't ask) so the additional pressure of condoms can make a hard task worse so it sounds a good option. Sorry m8 too much detail so your a gay jew and I am partially paralysed, we make a good team.

Edited November 6, 2014 by japsportscarmad

[Jingthing]

PrEP is only for people who can be identified as being high risk. For example not just gay, but sexually active multiple partner and gay, or in a mixed HIV status couple. Perhaps in future if a more convenient (on demand) PrEP becomes more prevalent, it will expand to people in lower risk groups that are TEMPORARILY engaging in high risk behaviors. Perhaps like a holidaymaker in Pattaya who has a boring life back home.

Edited November 6, 2014 by Jingthing

[japsportscarmad]

PrEP is only for people who can be identified as being high risk. For example not just gay, but sexually active multiple partner and gay, or in a mixed HIV status couple. Perhaps in future if a more convenient (on demand) PrEP becomes more prevalent, it will expand to people in lower risk groups that are TEMPORARILY engaging in high risk behaviors. Perhaps like a holidaymaker in Pattaya who has a boring life back home.

Never been to Pattaya, so not sure how boring it is or not but the PrEP sounds a good thing to be encouraged wether you are gay, straight or whatever.

[mitsubishi]

Condoms are crap I have a spinal injury to my neck it snapped (don't ask) so the additional pressure of condoms can make a hard task worse so it sounds a good option. Sorry m8 too much detail so your a gay jew and I am partially paralysed, we make a good team.

LOL!

Post of the month!

I'll say I've only ever had a condom break ONCE while in 'action' and that was because it was one of the 'thai-sized' ones.

[Jingthing]

...

I'll say I've only ever had a condom break ONCE while in 'action' and that was because it was one of the 'thai-sized' ones.

PrEP is never to be considered as a replacement for condom usage, but rather something to ADD to condom usage. Again, only for certain people who have been identified as very high risk to become infected with HIV.

[japsportscarmad]

...

I'll say I've only ever had a condom break ONCE while in 'action' and that was because it was one of the 'thai-sized' ones.

PrEP is never to be considered as a replacement for condom usage, but rather something to ADD to condom usage. Again, only for certain people who have been identified as very high risk to become infected with HIV.

That would cover most tourists :-) going to gogo bars, that's high risk

[mitsubishi]

It's interesting stuff but condoms protect about other nasty stuff as well.

Correct, but be clear people are being told to use condoms AND PrEP. Just condoms provides pretty good protection (but consider the flaws mentioned) but condoms plus PrEP and evidence shows 99 percent protection. It is clear to me that the concept of PrEP in some form (even if it's very different like a special lubricant) is the wave of the future and condoms alone are going to start to be seen as NOT GOOD ENOUGH.

Calm down mate, we all hear you loud and clear. You've got a good thread started here.

I look forward to the day when something like a lubricant that does what the PrEP does as well as protect against other STD threats too. Hopefully this is just around the corner.

[japsportscarmad]

Hopefully ;-)

[Jingthing]

The current use of PrEP doesn't really yet include the temporary "on demand" protocol described in the recent research. That RESEARCH development is very new even in the west. For now the standard actual in practice PreP is Truvada pill once a day, every day. having sex or not. I do understand the psychology of WAITING for "something better" but there will always be something better in the future. That won't help the people who got infected who could have prevented who were WAITING for the something better.

[mitsubishi]

The current use of PrEP doesn't really yet include the temporary "on demand" protocol described in the recent research. That RESEARCH development is very new even in the west. For now the standard actual in practice PreP is Truvada pill once a day, every day. having sex or not. I do understand the psychology of WAITING for "something better" but there will always be something better in the future. That won't help the people who got infected who could have prevented who were WAITING for the something better.

So what are the SIDE-EFFECTS of this Truvada pill Jingle?

[japsportscarmad]

Jingthing your right there's always something better just around the corner. I thought it was cream not a pill.

How does the pill work?

That's the key is a creme m8

Edited November 9, 2014 by japsportscarmad

[Jingthing]

The current use of PrEP doesn't really yet include the temporary "on demand" protocol described in the recent research. That RESEARCH development is very new even in the west. For now the standard actual in practice PreP is Truvada pill once a day, every day. having sex or not. I do understand the psychology of WAITING for "something better" but there will always be something better in the future. That won't help the people who got infected who could have prevented who were WAITING for the something better.

So what are the SIDE-EFFECTS of this Truvada pill Jingle?

http://www.advocate.com/31-days-prep/2014/10/20/what-expect-when-youre-prep

You may experience some side effects, and you may need to see your doctor more often than usual when you first go on PrEP so he or she can monitor you for side effects.

[Jingthing]

Some interesting thoughts on Truvada.
The retail cost in the U.S. is 1500 dollars a month which I guess not many people are paying.

Egads!

http://www.slate.com/blogs/outward/2014/12/05/truvada_the_gay_community_and_fear_considering_the_meanings_of_condoms_and.html

Can a treatment also be a symptom?

[inbangkok]

In Thailand the "high risk" population is not just the gay community, its is the ALL Thai population. Most, and in ALL social classes, do not have any knowledge and concerns about HIV infection.. To have sex with ANY Thai without protection, is playing with death.

I am gonna fix that last sentence for you.....

"To have sex with ANY person without protection, is playing with death (unless you know for a fact they are clean and you trust them)."

Edited December 6, 2014 by inbangkok

[Sheryl]

Indeed. Viruses are indifferent to nationality.

[Jingthing]

In the U.S. PrEP is now a political issue about getting full ACCESS to high risk people.

Again, talking here about Truvada or generics take DAILY to PREVENT HIV infection. Not the same thing as POST-EXPOSURE meds.

This still doesn't seem to be taking off in Thailand.

So my question is why?

Apparently based on another thread GENERIC Truvada here is available at a cost of 1 to 3 U.S. dollars a day. That's not bad at all.

It seems to me it is both a humane and economic benefit to get PrEP to all high risk people that want to take it, in Thailand, and globally.

The prevention rate when used properly is over 99 percent.

As far as the politics on the U.S. Contrary to what some might think, the U.S. doesn't have universal health care. It's a complex web and money still matters:

http://www.thebody.com/content/75532/prep-in-the-spotlight-sound-bites-from-creating-ch.html

PrEP Is a Social Justice Issue

Access to PrEP is dependent on having affordable health insurance and a prescription from a medical provider. While health care reform is expanding access to health care for many people, navigating the system to find a health plan that fits PrEP needs and a person's budget can be challenging. Even with insurance, high out-of-pocket drug costs have the potential to make PrEP unaffordable. In addition, some providers are still resistant to prescribing this life-saving medication to their patients. As a result of these health care disparities, oftentimes communities most vulnerable to HIV are not able to fully benefit from PrEP.

[sunnyjim5]

In the U.S. PrEP is now a political issue about getting full ACCESS to high risk people.

Again, talking here about Truvada or generics take DAILY to PREVENT HIV infection. Not the same thing as POST-EXPOSURE meds.

This still doesn't seem to be taking off in Thailand.

So my question is why?

Apparently based on another thread GENERIC Truvada here is available at a cost of 1 to 3 U.S. dollars a day. That's not bad at all.

It seems to me it is both a humane and economic benefit to get PrEP to all high risk people that want to take it, in Thailand, and globally.

The prevention rate when used properly is over 99 percent.

As far as the politics on the U.S. Contrary to what some might think, the U.S. doesn't have universal health care. It's a complex web and money still matters:

http://www.thebody.com/content/75532/prep-in-the-spotlight-sound-bites-from-creating-ch.html

PrEP Is a Social Justice Issue

Access to PrEP is dependent on having affordable health insurance and a prescription from a medical provider. While health care reform is expanding access to health care for many people, navigating the system to find a health plan that fits PrEP needs and a person's budget can be challenging. Even with insurance, high out-of-pocket drug costs have the potential to make PrEP unaffordable. In addition, some providers are still resistant to prescribing this life-saving medication to their patients. As a result of these health care disparities, oftentimes communities most vulnerable to HIV are not able to fully benefit from PrEP.

Responsible behaviour is cheaper than $21+/week.