The increasing demand for pre-exposure prophylaxis (PrEP) is
likely to increase the likelihood that some marginalised individuals living
with HIV sell some of their prescribed medication to pill brokers and drug
dealers, according to a study presented to the Conference of the Association
for the Social Sciences and Humanities in HIV in Stellenbosch, South Africa last week.
Steven Kurtz told the conference that several reports have
documented street markets for diverted antiretrovirals (ARVs) in the United
States. His own research focuses on south Florida, where he recruited 147
HIV-positive men who have sex with men (MSM) who regularly use cocaine, crack or
heroin. He purposively sampled (over-recruited) individuals who had sold or traded their
antiretrovirals, so that he could better understand the factors associated with doing so.
Economic vulnerability is the key explanation. Within this sample, men who had recently sold ARVs were
more likely to have an income below $1000 a month, to have traded sex for money
or drugs and to be dependent on drugs. Age, race and education were not
relevant factors. Unsurprisingly, men who had sold their HIV treatment had poor
levels of adherence to it.
larger study of substance-using people of all sexualities and genders,
homelessness was a significant predictor of diverting ARVs, as was being a man.
Individuals reported selling their medication an average of seven times,
indicating that it was an occasional practice.
Returning to the MSM study presented at the conference, antiretrovirals
were most commonly sold to pill brokers (84%) and street drug dealers (41%).
People who didn’t sell their drugs also reported being approached by these
traders. Less frequently, ARVs were sold or given to individuals who would use the pills
themselves, sometimes in exchange for recreational drugs or sex.
The principle reasons for diverting antiretrovirals were
because the person needed cash for drugs or alcohol (74%) or for living
expenses (23%). Additionally, some individuals had leftover medication or
wanted to help someone.
The antiretrovirals which participants most commonly
reported selling or giving away were Truvada
(44%), ritonavir (39%), Atripla
(38%), atazanavir (21%) and darunavir (17%). They would earn $80 or $100 for a
Kurtz said that some of the demand for Truvada is likely to come from its use as PrEP. He said that there
was little evidence that individuals purchased ARVs from the black market for
self-treatment of HIV infection (especially as people living with HIV have
relatively good access to health care in the US), but that the illicit use of Truvada for prevention purposes has been
Many HIV-negative people who are at high risk of HIV
infection do not have health insurance, perhaps making them more likely to turn
to the black market. However, informal use of the drugs as PrEP entails many
risks – interruptions in the supply of pills, lack of systematic HIV testing
when restarting PrEP, use when unknowingly infected with HIV, lack of
side-effects monitoring, and counterfeit pills.
Moreover, an associated qualitative study by the same
researcher showed that, among a small sample of high-risk HIV-negative young
MSM, misinformation about PrEP was widespread. Among those men who had heard
of PrEP, few described it as a medication prescribed and monitored by a
Most thought that it could be acquired through informal
“Who doesn’t know
somebody that’s HIV-positive, you know? ‘Girl, sell me one of your pills! Or
give me a couple of weeks’ worth.’”
“This guy I filmed
[pornography] with, he was positive. He’s undetectable on meds. He gave me two Truvada, one for that moment, and one for the next
day as a kind of preventative. I got tested two days afterward.”
It was usually understood as a variation on the ‘morning
after’ contraceptive pill:
“You can have bareback
sex all you want as long as you take these drugs. Right after you do it,
though. It’s like the plan B pill for us.”
While these quotes are suggestive, it’s important to note
that only one participant (the one who had filmed porn) had actual experience of
getting Truvada through informal
channels. Kurtz’s research provides more insight into those selling pills than
those buying them.
He argued that HIV-negative gay men need
accurate and accessible information on how PrEP can be effectively used, as
well as clear avenues for access to it. Otherwise, there is a risk of unsafe and
ineffective informal use of traded Truvada
by HIV-negative people, while HIV-positive people who have sold some of their
medication risk drug resistance and treatment failure.
“The potential intersection of widespread ARV street markets
and misinformed at-risk populations about the effective use of PrEP is a major
public health concern,” Kurtz concluded.