Californians can now get prescriptions for a daily HIV-prevention pill through an app, with the medicine delivered to their door in a matter of days.
The San Francisco-based startup Nurx, which started by offering birth control in 2014, announced at the end of March that they would begin offering Truvada as "PrEP," or an HIV preexposure prophylaxis. People looking to get on PrEP can sign up via Nurx's website or smartphone app. After answering screening questions and going to a lab for blood work, patients are mailed a three-month supply of Truvada. According to Nurx co-founder Hans Gangeskar, they've gotten "a lot of users" in the first three weeks.
Nurx is hoping that this Silicon Valley approach to drug delivery will get more people on PrEP, especially populations like gay men of color, transgender women, and sex workers that are hardest to reach. When taken daily, the drug has been shown to reduce new HIV infections by 92 percent, and has been widely endorsed as a crucial means of stemming the spread of HIV. Despite that, many people still struggle to access PrEP; doctors may be unfamiliar with the drug or unwilling to prescribe it because of lingering stigma.
Approximately 40,000 new cases of HIV are diagnosed in the US annually
Enter Nurx. "When you go to the doctor's office, you're in someone else's space, you're on their time, you don't have control over this [process]," Gangeskar tells The Verge. "We're trying to change that."
Nurx exists to connect patients to willing doctors, though it's not as simple as ordering medication from your phone. Users begin by answering questions about risk factors (such as their number of sex partners, condom use, STI diagnoses, and possible HIV exposure) and any previous experiences with PrEP or PEP, the post-exposure prophylaxis. Then one of the five doctors currently working with Nurx reviews the answers. If the reviewing doctor deems PrEP appropriate for the patient, they send the user to get tested for HIV, hepatitis, and kidney function. These essential tests must be repeated every three months to make sure patients have not become HIV positive. Although Truvada is used to treat HIV, if an HIV-positive person takes it without other antiretrovirals it can create drug resistance.
After those checks, Nurx sends a prescription to one of its pharmacies. Doctors' and labs' fees are billed through insurance — or through various patient assistance programs — and shipping is free. So "for most people to get PrEP it's $0," Gangeskar says. Nurx makes money by charging pharmacies for working with them; Gangeskar declined to say what pharmacies pay for that privilege.
Truvada was first approved over a decade ago to treat HIV infections. In 2012, with approximately 42,000 new HIV diagnoses that year, the Food and Drug Administration approved the drug for preventing infection in HIV-negative people. Since then, the World Health Organization, Centers for Disease Control, National HIV / AIDS Strategy, various state and city departments of public health, and HIV / AIDS nonprofits have embraced PrEP. In 2015, the CDC noted that if even half of gay men at high risk for getting HIV took PrEP with "moderate adherence," new HIV infections could drop by almost one-third over the next 20 years.
Nurx prescribes PrEP and delivers it by mail within days
But for that drop in infections to happen, doctors have to know about the treatment regime. The very same CDC study said that a third of healthcare providers had not heard of PrEP. And even if doctors are aware, that doesn't guarantee they'll be willing to prescribe it.
It's easy to get PrEP in San Francisco, where there's a thriving gay community and robust HIV prevention efforts. But it is much harder to find in rural areas. For example, in far northern areas like Shasta County, there is only one clinic willing to prescribe the prophylaxis, according to the website Please PrEP Me, which allows Californians to search for PrEP prescribers.
"We had a guy from Willits [California] who actually spent two hours with his primary care provider going over the CDC recommendations — and, you know, they're government publications so they should bear some weight — saying what PrEP is and why he needed it," says Pierre-Cédric Crouch, director of nursing at the San Francisco AIDS Foundation. "And at the end of that conversation, the provider still refused to provide him PrEP."
Crouch noted some doctors are reluctant to prescribe PrEP, because they believe that it should only be offered to people with HIV-positive partners or only prescribed by HIV specialists, while others simply do not know enough about the drug.
One third of healthcare providers haven't heard of PrEP
It's not just doctors, either. In 2014, the AIDS Healthcare Foundation argued that PrEP was not successful enough to be so widely endorsed, and called it "a public health disaster in the making." Nicknames like "Truvada whore" began to circulate, which made potential users ashamed of taking the drug.
In San Francisco, thanks to an aggressive public health campaign, that stigma is fading. In 2014, San Francisco Board of Supervisors member Scott Wiener published an article in The Huffington Post, revealing that he is on PrEP. Wiener has seen a change since his disclosure, with more people willing to talk about using PrEP. "So when people see that their friends are taking it, or people just talk about it with their friends, it normalizes it," he says.
Crouch agrees. Both Crouch and Gangeskar noted that men on dating apps like Grindr or Scruff often include in their profiles that they're on PrEP. On World AIDS Day in 2015, Grindr stated that 25 percent of surveyed users are taking the prophylaxis.
But some have concerns about prescribing medicine through an app. Nir Eyal, a medical ethicist at Harvard University, believes that the technology has the potential to remove barriers to access to PrEP, but worries about patients self-reporting symptoms and patient-doctor communication.
Men now brag on Gridr and Scruff about being on PrEP
Relying on a self-reported questionnaire to prescribe a drug leaves too much room for error or deception, Eyal believes. Patients could falsely report symptoms, or neglect to mention other contraindicated medicines they are taking, so as to obtain a drug.
Arthur Caplan, a doctor and bioethicist at New York University, shares these concerns.
"I think there you still need that initial visit," Caplan says. "It's nice to get people into the doctor so they can probe around a little bit, see what else might be going on." He noted that seeing a patient in person might help a doctor diagnose a problem, like sexual abuse or drug addiction, that wouldn't be captured by a questionnaire. He would want doctors on prescription apps use a phone's or computer's built-in camera for a brief patient interview, probing into the patient's medical history, and inviting him or her in for a routine checkup.
Nurx, instead, believes that the anonymity of an app will reach people who have hesitated to talk to their doctor about PrEP.
"You know, even on birth control, which we've been doing for a little while now, people often come straight up and say to us, ‘You know, I was able to ask you things that I wouldn't have dreamed of asking in the doctor's office,'" Gangeskar says. "I don't think it's so much about like making [PrEP use] more private, but I think it's like giving people the healthcare they need on their own terms," he said.
"I think it's like giving people the healthcare they need on their own terms."
When a patient begins a PrEP regime through Nurx, he or she is counseled via phone or secure messages on how to take the drug. Eyal, however, believes that counseling via messenger is not enough.
"We know how we all neglect to read the small letters when we get directions, and, indeed, when we get prescribed medications. It's important for somebody to review these details with the patient," he said.
Nurx's ability to address stigma also remains to be seen. Wayne Steward, a doctor at the University of California, San Francisco's Center for AIDS Prevention Studies, noted in an interview that apps are useful for getting around stigma, but they do not address that stigma on a deep level.
"[An app like Nurx] doesn't necessarily get rid of the stigma, it just allows you to cope with it," Steward says.
This is because Nurx doesn't address doctors' lack of knowledge about PrEP or unwillingness to prescribe it, let alone deeper societal stigma about HIV. Instead, they sidestep these issues by working with those already in favor of PrEP, and by minimizing patient-doctor interaction.
Nevertheless, all those with concerns also discussed the upsides of prescribing PrEP via an app. Eyal notes that removing some barriers to access "could turn out to go a surprisingly long way" toward preventing HIV. And Caplan is even more optimistic.
"I think it's the future," he says. "Are we ready to do it today? No. How long will it take? I'm not sure. But it's inevitable."