In October, the U.S. Food and Drug Administration approved the drug Descovy to be used as a regimen for preexposure prophylaxis, or PrEP—the use of a daily pill to prevent HIV—for cisgender men who have sex with men and for transgender women. Prior to this approval, Truvada had been the only FDA-approved PrEP regimen, starting in 2012.
The introduction of Descovy into the country’s HIV prevention efforts is a big deal—we now have multiple options for PrEP for the first time. But from my position as a public health worker and HIV educator, I’ve begun to observe a disturbing trend in the way gay and bisexual male communities are talking about this exciting shift. Instead of simply assessing, in consultation with our medical providers, the two drugs and their respective benefits and drawbacks for us as individuals, we’re starting to treat them like iPhones or handbags—status symbols where newer is always better, and if you haven’t got this season’s upgrade, are you even living?
This is not a smart way of approaching medicine, but the reasons for its emergence are not entirely our fault. A major factor is the efforts of Gilead—the maker of both Truvada and Descovy—to move patients from the former to the latter as quickly as possible. Indeed, by one estimate, it’s already converted 10 percent of Truvada users to Descovy and could convert a total of 50 to 60 percent by September. How is the pharmaceutical giant achieving this? With confusing messaging about safety, an unlikely assist from misleading Facebook ads, and, perhaps most influentially, a preexisting gay penchant for keeping up with the Jonathans.
Let’s begin with the safety question. The top-line thing to know here is that both drugs are, in fact, quite safe. The DISCOVER clinical trial comparing Truvada and Descovy for PrEP (funded by Gilead) concluded that both are highly effective at preventing HIV, with relatively similar safety profiles. A small percentage of Truvada patients may experience significant renal or bone density issues, while a small percentage of Descovy patients may experience increased cardiovascular risk and/or weight gain. (Advocates also suggest that the risk of significant cardiovascular effects may be underestimated because of the lack of racial diversity in the Descovy PrEP trial.)
Yet despite the relative safety of Truvada (it is comparable to aspirin), Descovy is becoming an increasingly popular PrEP option, as the conversion estimate shows. Generally, one might change regimens because of the aforementioned side effects. But only a fraction of switches from Truvada to Descovy could, based on the low incidence of such effects in the first place, be happening for these reasons. So why are so many gay men in such a rush to get on “PrEP 2.0”?
While hard data on this trend hasn’t yet been collected, some providers have a theory: “Anecdotally, it seems that people are being switched due to a perception of improved safety with Descovy,” David Holland, an associate professor of medicine at Emory, told me. And this perception of safety—of a clear, universal “improvement” in Descovy—is, in the eyes of critics, being actively encouraged by Gilead. In an interview with TheBodyPro, Douglas Krakower, a Harvard professor and co-author of a recent commentary criticizing the company’s promotional methods, described an aggressive campaign: “I get emails, online and print ads. I got a poster about PrEP with Descovy. I had outreach from Gilead with invitations to attend informational dinners about Descovy. I talked with a rep from Gilead who said the favorable safety profile of Descovy made it optimal, which is not correct. It was not a neutral presentation of data.” (Gilead did not respond to a request for comment.)
Regardless of accuracy, once the “safer for everyone” meme trickles down from conferences and Gilead representatives to medical prescribers, it eventually makes its way to patients. Then, with relative ease, the notion of Descovy’s supposed side effect–related superiority spreads through social networks in conversations between friends and strangers in person and online. In fact, the advocacy group PrEP4All convincingly argues that Gilead has been positioning Descovy as a “safer” Truvada for years, since the time Descovy was approved as an HIV treatment drug in 2016.
Why might that be? Generic Truvada will finally be available in the United States later this year. This objectively poses a huge threat to Gilead’s monopoly on the PrEP market and, therefore, its profits. Truvada costs around $1,700 per month without insurance or other assistance; Descovy costs the same. (To be fair, Gilead offers a copay assistance program, making it free for some PrEP users with insurance, but others may hit its $7,200-per-year limit depending on their coverage.) Gilead is even actively marketing Descovy on its official Truvada website. Introducing Descovy about a year before generic Truvada arrives in the U.S. allows Gilead to ramp up its presentation of the new PrEP option as the “safer” alternative to Truvada to both prescribers and PrEP users, and thus potentially maintain its hold on the market.
Now for the Facebook ad element, which sounds counterintuitive at first, so bear with me. Recently, ads for a lawsuit against Gilead regarding Truvada’s safety as an HIV treatment (rather than prevention) drug have been popping up across social media platforms, hyperbolizing Truvada’s potential side effects. The lawsuit’s focus, however, is not always clear in these ads, leading many to view them as having to do with PrEP. For folks like me who work in public health, these ads are like an HIV prevention boogeyman. They are scary; they give would-be Truvada users the false sense that Truvada “isn’t safe,” contrary to what we have been claiming for years. While Gilead, again, is the target of the lawsuits, these advertisements may actually work in the company’s favor by making Truvada seem inaccurately deleterious, leaving Descovy as the only viable PrEP option and driving patients to demand it over Truvada. (To its credit, Gilead has previously made a statement applauding advocacy organizations for calling to remove these advertisements from Facebook.)
But if the “Descovy is better” notion’s origins are in Gilead’s interest and perpetuated by inaccurate lawsuit advertisements, its widespread dissemination has been exacerbated by social media users—particularly gay and bisexual men. Across different platforms, from Twitter to Instagram and beyond, some have been posting about their transitions to Descovy in a way that reinforces a faulty hierarchy of biomedical HIV prevention options. And that may ultimately help stigmatize PrEP options that will soon be much more affordable.
Social media generally puts us in competition with one another. The posts we see create an “economy of envy,” as we show off the material goods we acquire and the experiences we live in an effort to display our best lives. Gay men (myself included) are certainly subject to these continual acquisitive displays: concerts of the pop divas we stan, trips to different cities’ Prides, new clothes, and so on. The framing of Descovy as an upgrade, as opposed to an alternate option, situates a biomedical intervention as any other consumer good, subject to our tendency to want to keep up with fashion. It follows trends of what’s “in” and what’s “out.” It is something to get excited over. It is an item about which you can share your thoughts and experiences, akin to a YouTube beauty influencer reviewing an eye shadow palette. Descovy is Chanel and Truvada is Walmart.
Like a plotline from a rejected Black Mirror episode, the version of the HIV prevention drug you take seems to be morphing into a status symbol, intentionally or not. Displaying one’s acquisition of Descovy plays into our proclivity to show off under the guise of awareness and education. Yes, we can use Descovy as a conduit to open up larger conversations about PrEP and ongoing HIV prevention efforts, but these posts fall short without that substance. Instead, these posts make knowledge about and access to newer (though not necessarily better) PrEP options into a boastful display, a commodification of HIV prevention. When generic Truvada is introduced, I would not be surprised if we continue to see a stratification of “status” based on which PrEP regimen you can afford.
Yes, there are real reasons to switch PrEP regimens, such as in the case of people who experience decreased renal functioning. (This happens in approximately one of every 200 users.) However, doctors agree that Truvada is generally safe and well-tolerated; in fact, New York City health officials recently recommended to keep Truvada as the first-line PrEP regimen. In situations where the decision to switch regimens is not based on clinical necessity, moving to Descovy may just be the result of pressure: from Gilead and from one another.
PrEP users don’t need to submit to peer pressure. It’s exciting to have options for PrEP and easy to understand the allure of Descovy, questionable claims about safety and all, but switching existing Truvada patients to a similarly safe and expensive drug won’t do much to curtail HIV in the United States. Instead, that energy should be directed toward lowering pharmaceutical costs and increasing insurance access, among other targets that actually help decrease HIV infections overall. Health equity—not taking the newest, coolest pill—should be our greatest priority.