HIV Pre-Exposure Prophylaxis and Sex Work in Canada 2016

We need to do more work to raise awareness so that there can be some women on PrEP
to even start to study, at least in our study.
Q But isn’t that sort of putting the cart before the horse? I mean we don’t know if this
drug is safe. And, we already do know that loss of kidney function can be pretty serious
for women. So, to get more women on PrEP, to see if it’s safe, is kind of, I don’t know. I
don’t like it.
A We can spend more time talking about the safety. I feel like there is a pretty large
evidence base on the safety of TDF [tenofovir]. The company that a manufactures it,
paradoxically has, I fear, been successful in trying to convince us that it may be less safe
than they tried to tell us it was a few years ago. I don’t know whether this was brought up
earlier. Did anyone talk about TAF? We should maybe talk about that. Let’s just talk about
what’s coming up. OK, Truvada® is a combination of two things: TDF plus emtricitabine
[FTC] in one pill. We’ve been using that pill in HIV therapy for years and years and
years. We have a very good understanding of what the safety profile is. And, like I was
mentioning before, I would say more than 2/3 of folks who are living with HIV who are
in-care—and I’m talking about Canada—are using TDF and FTC as part of their regimen
because the safety has been so high. Although, we did know that there was a renal signal.
There have been some rare issues with kidney function, it was a known issue and the
company has been trying to say: “Don’t worry about that. It’s not a big deal. It’s very
rare, don’t worry about it.” The drug, TDF—you heard earlier—is going “off-patent”
next year. A few years ago, the company said: “You know what? There’s this other version
of tenofovir that we’ve got coming out, and it’s called TAF [tenofovir alafenamide].
We’re going to package it together with FTC in a pill.” That will be like a version 2.0 of
Truvada®. And the advantage of it, for a bunch of biological reasons that we don’t need
to get into, is that it’s safer from the bone and kidney perspective. They’ve done clinical
trials and the drug is now licensed in Canada. We are already able to prescribe it and
many of us are doing so. It’s safer from a bone and renal standpoint and that’s great for
everybody, but the thing that it’s there to replace was pretty damn safe, too. That’s my
personal opinion.
Q I feel concerned about hearing safety talked about as the same for treatment as
for prevention. In medical ethics you have an entirely different standard for prevention.
I’m prepared to live with bone density problems and kidney problems and whatever else
because the alternative is death. But, to put that drug into a healthy body is a different
thing. It’s the discourse I have a problem with. The discourse is: “tenofovir is safe.” I
want to hear about tenofovir safety for prevention and tenofovir safety for treatment
very separately, because we’ve talked about 16-year-old healthy kids who are at risk of
unwanted pregnancy, STIs, HIV, a whole lot of stuff. To put tenofovir into a 16-year-old
HIV-negative body is very different from a 60-year-old HIV-positive body. We’re hearing
“it’s safe.” Well, for who? Medical ethics says safety for preventative stuff really has to be
the absolute highest.
A Yes I agree—I was trying to emphasize that there is a lot of data on the safety of
Truvada® as PrEP including in women earlier, when speaking about the Partners PrEP trial
and TDF2 trial, as well as the safety of Truvada® as treatment in men and women living
with HIV.
Q In terms of pregnancy, let’s say there was a youth or a young adult who was a sex
worker who became pregnant. What would happen to that person’s pregnant body, as
well as the unborn body if that person chose to go on PrEP? Or if they were on PrEP? Any
information you could give me to pass along to either warn or reassure?
A So, information is limited. The best thing that I can think of comes out of that
Partners PrEP trial I was talking about in east Africa—Kenya and Uganda. So there’s
context issues. Like in Kenya, again, a population maybe different from Canada in many
ways. I think if I remember the data correctly there were a couple hundred pregnancies
and they were able to show the rate of successful live births and the gestational age which
is another model for health of the pregnancy. The numbers were similar between those
taking Truvada® and the trial group who were receiving a placebo. Out of interest, they
looked at the flip-side of the scenario: if the person whose sperm resulted in the pregancy
was taking PrEP and there was no difference.
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