Though Israel agreed last year to subsidize pre-exposure prophylaxis (PrEP) drugs to prevent HIV, a major victory for the gay community, the number of those using the drugs is small and has not led to a decrease in the number of infections. Now, the medication is once again being submitted for inclusion in a state-funded list of medications – this time with a request for a lower co-pay.
The campaign to include PrEP drugs in the state-funded list was one of the most publicized struggles of the gay community within the health system in recent years. The struggle succeeded, and the medication was added to the basket last year.
In 2020, 362 new cases of HIV infection were reported in Israel – a figure indicative of a 6.7 percent decrease relative to the previous year. More than one-third of those infected – 132 in number – are males who have sexual relations with males, as compared to 119 in 2019 and 130 in 2018.
The Ministry of Health together with the HMO Maccabi Healthcare Services conducted a study that tracked the use of PrEp drugs (the most common of which is Truvada) between 2017 and 2019 – after the country's health maintenance organizations began subsidizing the medication. The study examined purchases of the drugs, the medical supervision and the clinical outcomes of its users. The study sample consisted of a group of 757 users, all of whom, except for one woman, were men.
Consistent use of the drug was observed only among 29.9 percent of the group. Another 39.9 percent used it sporadically, with the first break occurring after four months on average, while 33.3 percent gave up using the drug entirely.
The clinical instructions for using PrEP require periodic medical checkups, including tests for kidney functioning, HIV and other sexually transmitted diseases. It is necessary to be tested once every six months or once a year, depending on the test.
“Despite these instructions, we found that very many of the PrEP users did not report for regular testing. Considering the potential for negative side effects of PrEP, these lackluster findings are cause for concern,” stated a recently published Health Ministry report on the topic of HIV and AIDS in Israel.
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The report also notes that at the outset of the study the rates of STDs that are not HIV were consistent with the rates of STDs among men who have sexual relations with men in Israel. However, after a year of PrEP use in the country, the estimated rate of STDs among the group was two to four times higher.
“Despite the hope that use of PrEP would lead to a decrease in the number of cases of HIV infection among men who have sexual relations with men, the absolute number of men diagnosed with HIV has remained constant during the past few years. The constancy of new HIV cases among men who have sexual relations with men in 2020, despite the availability of PrEP, gives rise to concern,” the report says.
Not only in the Health Ministry is there concern about the bleak findings on the use of drugs to prevent HIV. A position paper published this week by the AIDS Task Force to mark World AIDS Day states: “We are perturbed by a number of common phenomena in the sex life in the community, phenomena that cause damage that the correct use of the strategies of advanced prophylactic strategies that are available to all of us could minimize. Nearly five years after PrEP treatment (treatment that prevents infection) came into use in Israel, the good news it was supposed to have brought with it has yet to arrive optimally.”
The task force position paper also includes the results of a community internet survey in November of this year by Bela Doeget (an organization for encouraging safe and protected sex in the gay community) of 505 people who identify as LGBTQ community and have sexual relations with men. Of the sample, 34 percent responded, with about 50 of them using PrEP irregularly, surrounding a specific event.
The survey also found that about 50 percent of those who used the medications do not regularly use a condom. Seventy-three percent reported that they had contracted an STD since they began using the medication. Only 40 percent of the participants in the survey who had been infected with STDs knew all of their partners. Forty-five percent of the users of PrEP reported that they had tried to persuade their partners not to use a condom.
The gay community’s struggle to include the PeRP drug Truvada in the public health basket was accompanied by a debate over the question of whether the public coffers should pay for drugs to prevent HIV for people who insist on having sexual relations without a condom, at the expense of other medications and procedures.
The high price of the drug (about 1,800 shekels a month) was depicted as the major obstacle to use of the drug in Israel on the way to widespread use of the medication and a significant decrease in the rate of infection. The efficacy of the drug depends on regular usage under medical supervision. In 2017 the HMOs began subsidizing the drugs through their supplementary insurance programs, at 300 to 500 shekels a month. Since 2020 it is available as part of the public health basket with a co-pay of 10 percent of the price of the drug (about 200 shekels a month). Nevertheless, the dramatic change that had been expected – has not happened.
“There is a certain amount of disappointment. We had hoped we would see a more significant decrease in infections. This is a drug that has improved the quality of life, both psychological and physical, for very many people but we are still not where we had hoped to arrive. We will continue to fight to get there,” says Dr. Gal Wagner Kolasko, chairman of the Israel LGBT Medical Association and director of the Clalit HMO Gan Meir Clinic located in the LGBT Community Center in Tel Aviv, who is among the leaders of the campaign to introduce the drugs for use in the health system in Israel.
Moreover, he notes that this is not a phenomenon unique to Israel. “PrEP is not succeeding in sufficiently reaching its target population – this is something worldwide,” he says. According to him, there are reasons for this, among them the cost of the co-pay, which is currently 200 shekels a month.
“A large part of the target population has no problem paying that much. The problem is with the more excluded parts of the population, like trans women or young people who have come out of the closet and have been thrown out of their homes and other groups in the community who are at higher risk, and also don’t use condoms.” In the Bela Doeget survey, 28 percent of those who do not use the mediation reported that one of the reasons is the high cost.
“On the one hand, there is a lot of awareness among a certain and very large group in the community, but on the other hand awareness is lacking in another place in the community and in the context of less involved individuals, whom we don’t know as well but are sexually active ‘in the shadows,’” says Wagner Kolasko.
Whether or not there is a direct connection, the introduction of the PrEP drugs in Israel in recent years has been accompanied by a surge in reports of STDs, as noted in the Health Ministry report.
According to AIDS Task Force chairman Idan Barak, “What mainly worries us is the ‘side effects’ of taking PrEP – its influence on the climate within the community. We are seeing incorrect taking of the drugs, pressure to have unprotected sexual relations, a decrease in the ‘legitimacy’ of condom use. We stress that we are in favor of PrEP and we believe it is the solution, not the problem, but on condition that it is used correctly and a holistic solution is created for the challenges it brings along with it: STDs, social challenges, incorrect use and more. And its price is really not reasonable.”
According to Dr. Wagner Kolasko, what is behind the precipitous rise in reports of STDs is not necessarily the result solely of the introduction of PrEP or various phenomena or trends that characterize sex life in the gay community. “In recent years there has been a fundamental change with regard to testing for STDs. Up until a year or two ago, many fewer people were tested for STDs. Since then, the kind of testing has changed, and new tests have been introduced. The use of PrEP also requires testing for STDs. Thus, when more people are tested, more are discovered, especially asymptomatic cases and in the past those didn’t go to get tested. However, we can’t ignore the fact that people who take PrEP, using condoms less and having a lot of sex are getting infected more,” he says.