Why aren’t more gay men on the HIV pill?

Damon Jacobs has lost so many people he's loved that he said he's become numb to it. For the first two decades of his sexual life, he lived with the constant fear of contracting HIV.

“It seemed like it was going to be this never-ending thing that I was going to have to be coping with my entire life," said Jacobs, a therapist in New York City.

Then, two years ago, the FDA approved the first drug to prevent HIV infection. Truvada is part of a new class of drugs called PrEP, or pre-exposure prophylaxis, which blocks the ability of HIV to reproduce. If taken every day as directed, Truvada can reduce the risk of infection by 99 percent, one National Institute of Health-funded study found in 2012.

Since it was approved in July 2012, Jacobs has taken the little blue pill every day and says it’s completely changed his sex life.

“I can’t think of anybody who has died who wouldn’t have taken PReP if they had had the option to do so,” he said.

But now that people do have that option, not many are taking it.

Last week, the World Health Organization strongly recommended that men who have sex with men and might have substantial risk of infection consider taking PReP, along with the use of condoms. But from January 2011 to March 2013, fewer than 1,800 Truvada prescriptions were filled in the U.S. – and nearly half of the patients were females, according to a study by drugmaker Gilead Sciences.

Those leading the charge against PrEP may come as a surprise; many are AIDS activists. The multinational AIDS Healthcare Foundation, for example, has been vehemently fighting Truvada for two years. It even urged the FDA not to approve it.

“We believe, based on our experience being the largest AIDS organization in the world, and providing care to 300,000 worldwide for over 27 years in many, many countries, is that the vast majority people who take PrEP will not be able to remain adherent,” said Tom Myers, the spokesman and general counsel of AHF. “If they are not adherent, there is a potential that their risk of HIV infection increases rather than decreases.”

In other words, people on PrEP may stop using condoms and forget to take the pill every day, and become infected with HIV.

One 2010 multi-nation study of “high-risk” gay men, transgender women and other men who have sex with men showed that while PrEP lowered the infection rate by 73 percent for people who used the treatment more than 90 percent of the time, fewer than half of patients took the pill every day, as prescribed.

“Those people are likely the people who would not be giving any protection anyway, said Dr. Anthony Fauci, one of the nation’s leading HIV experts. “So I think you don’t want the perfect be the enemy of the good.”

Fauci, the director of the National Institute of Allergy and Infectious Disease, believes PrEP could even mark the tipping point of the epidemic.

“We have had the misfortune, as a generation, of seeing one of the most devastating pandemics in the history of mankind,” he said. “Now we have the opportunity for the next generation – my children – to see that point where we can actually rid the world of this pandemic. I'm going to be here when they nail that coffin.”