Black market for Truvada PrEP may undermine treatment adherence in marginalised people living with HIV

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.

Glossary

sample

Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).

drug resistance

A drug-resistant HIV strain is one which is less susceptible to the effects of one or more anti-HIV drugs because of an accumulation of HIV mutations in its genotype. Resistance can be the result of a poor adherence to treatment or of transmission of an already resistant virus.

qualitative

Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

treatment failure

Inability of a medical therapy to achieve the desired results. 

In a 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 month’s supply.

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 documented.

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 physician.

Most thought that it could be acquired through informal networks:

“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.

References

Kurtz S et al. ARV street markets and informal PrEP use by MSM in South Florida: the context of limited access. 3rd Conference of the Association for the Social Sciences and Humanities in HIV, Stellenbosch, South Africa, July 2015.