It's been nearly three years since the federal government approved Truvada, a daily pill hailed nationally as a miracle drug because it can prevent HIV infections.
But until this week, Los Angeles County hadn't begun to spread the word and distribute the medicine despite being the second-largest epicenter of HIV and AIDS in the country.
That's partly because county health officials were unsure they would get the necessary support to provide the drug, which has been somewhat controversial, said Supervisor Sheila Kuehl.
The prevention method, known as pre-exposure prophylaxis, or PrEP, is much less effective if not taken correctly, and some say it could inadvertently increase HIV infections if it leads gay and bisexual men to stop using condoms.
That political hurdle was cleared when supervisors delivered their endorsement this week. They passed a Kuehl motion that would craft a plan to get the medicine in the hands of people who need it at county-run and community clinics.
"If you have a tool that could help people not get HIV, it's completely immoral not to use it," Kuehl said.
Home to an estimated 60,000 people who've been infected with HIV, Los Angeles County will now be able to catch up with other cities — including San Francisco and New York — that have made the drug a central tenet of their HIV-prevention strategy, said Mario Perez, director of L.A. County's HIV prevention program. About 1,850 people in the county contract the virus each year.
"We've always enjoyed a fairly progressive, fairly advanced HIV response, and this is one area where we've fallen behind," Perez said in an interview Wednesday. "It's good to know that our policy is on the same side as science."
He said Truvada — manufactured by Gilead Sciences — would remain a piece of the program's broader strategy, which still views condom use as a primary prevention method, as well as HIV testing to identify who has already contracted the virus.
But AIDS Healthcare Foundation President Michael Weinstein warns about overly promoting Truvada as a public health tool. Weinstein has been a vocal — and controversial — skeptic about the drug for several years. County staff had been reluctant to try to roll out a PrEP program in part because of pushback from Weinstein, according to Kuehl.
Though the U.S. Centers for Disease Control and Prevention say the medicine is up to 92% effective, one study found that people who took Truvada experienced a 44% reduction in HIV infection risk. Scientists said that was because many participants in the study did not administer the pill as directed.
Weinstein worries patients won't take the medicine properly — it must be taken once a day — and then also won't use condoms because they think they're protected. "That will lead to more infections rather than less," Weinstein said.
He's not against the use of PrEP, he said. He just thinks it should be considered on a case-by-case basis, and that the county should focus its resources on those who are already infected.
Dr. Mitchell Katz, head of the county's Department of Health Services, said he supported the push to disseminate information about the medicine. But he said it needed to be differentiated from other public health campaigns that are encouraged for everyone, such as condom use and vaccinations.
Patients must decide, with their doctors, whether PrEP is right for them by discussing the strict medical regimen and the risks and benefits, Katz said.
"When it comes to PrEP, it's a different equation," he said. "It has to be distinguished from 'everyone should do this' to a thoughtful discussion."
Already, patients in L.A. County can visit doctors who will prescribe the medicine, and most insurance policies cover the cost, which is about $13,000 annually.
The plan approved this week will target low-income populations served by clinics in the county. Public health department officials were directed to create a plan and report back to the board within 30 days. It will probably cost about $1 million, Perez said. Most of the patients that the county expects to treat will qualify to receive the drug free or at reduced cost, he said.
Supervisors also added amendments to make sure the outreach is culturally relevant, and to craft a plan to distribute the medicine at county jails.
Many advocates say the medicine can be a game-changer, especially for high-risk groups such as young people of color and transgender populations.
Before PrEP, the question was "not if I will become HIV-positive, but when," said Grissel Granados, project coordinator in the HIV Risk Reduction Program at Children's Hospital Los Angeles, who is on the Presidential Advisory Committee on HIV/AIDS.
Granados drew a parallel between opposition to Truvada and opposition to the birth control pill, which some worried would lead to risky sexual behavior. Both, she said, are "one of the tools in our toolbox."
She said she sees PrEP becoming a permanent part of the nation's battle against HIV along with other kinds of counseling and testing. The use of the medicine acknowledges the fact that people don't always wear condoms, she said, and offers another level of protection.
Dr. Scott Kim, medical director for HIV medicine at the AltaMed clinic system, agreed, saying the medicine is a way for patients to take their health into their own hands, and should help stem the number of new cases. Next week, AltaMed — a chain of clinics in Los Angeles and Orange counties — will launch a pilot program offering PrEP to high-risk patients.
"If you think about the history of preventing and treating HIV, this is one of the first major tools we've had to directly empower people at risk of HIV in a way that helps them reduce risk," Kim said. "People in communities who are at greatest risk of HIV tend to be disempowered or disenfranchised.... Truvada is something they can take directly into their own hands."