Neil Canavan

July 10, 2013

KUALA LUMPUR, Malaysia — A disturbing number of men with legal access to antiretroviral medications are selling their prescriptions on the black market, according to new research.

These diverted medications mean an increase in the ongoing risk for HIV transmission and treatment failure because of resistance to therapy in those who become infected.

"We started receiving law enforcement reports about drug diversions around 5 years ago from major cities in the United States," said Steven Kurtz, PhD, from the Center for Applied Research on Substance Use and Health Disparities in Coral Gables, Florida. "It quickly became clear that street markets had developed for antiretroviral medications."

A previous study looking at this problem in impoverished men found a diversion rate as high as 20%. What Dr. Kurtz and his team set out to establish in their investigation was the extent of diversion practices in men who have sex with men.

Dr. Kurtz presented the research here at the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention.

The teams used the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) drug database to establish the prevalence of diversion. The system collects information from 300 law enforcement jurisdictions in the United States on sources of diversion such as undercover street purchases, arrests for distribution, and hospital and pharmacy theft.

It quickly became clear that street markets had developed for antiretroviral medications.

The RADARS data showed that 1518 cases of diversion had been investigated in 7 geographically diverse jurisdictions over 39 calendar quarters.

Dr. Kurtz and his team used this information to develop a survey about medical care, treatment, and adherence and diversion. It was completed by 515 men.

Of the 46.4% of respondents who were infected with HIV, 91.6% were receiving medical care. Nearly 80% of these men were prescribed much-needed antiretrovirals, yet 27.5% reported selling or trading their medications at some point, and 19.0% reported doing so in the previous year.

The respondents reported diverting their medications to share or trade with friends, to acquire money or illicit drugs, or to get rid of unused medications. Not surprisingly, antiretroviral diverters were more likely to be dependent on substances than nondiverters (74.5% vs 58.7%; P = .046), and more diverters reported recently trading sex for money or drugs (60.8% vs 32.6%).

Who is buying these drugs?

The demand for antiretrovirals increased with their recent approval for pre-exposure prophylaxis.

Party Packs Called MTV

"We've known from the literature and anecdotally that tenofovir, specifically, has been used for pre-exposure prophylaxis since at least 2009," Dr. Kurtz explained. It was even being distributed in clubs in Miami and other cities as a party pack called MTV, which consists of methamphetamine, emtricitabine plus tenofovir (Truvada), and sildenafil (Viagra). "That was a strong signal about what was going on."

"Frankly, we don't know who the purchasers are. Pill brokers are likely a big part of it, going in the back door of pharmacies, and recirculation. We need studies now to look at the demand side," he said.

"There's been a big black market in South Florida for many years," said Michael Weinstein, president of the AIDS Healthcare Foundation. "First off, Miami is the capital of Latin America. If the drugs are not available back home, you go to Miami. However, that's changed over time as treatment has become more common in poorer countries, so the incentive is now somewhat less."

Another market is individuals who are undocumented, explained Weinstein. "Usually, if you need to reduce the expense of your medications, you go to a government-sponsored clinic, but that requires providing some kind of information about yourself. Even though places like the Ryan White Program do cover undocumented patients, there are many who fear engagement with a government-run or any other type of formal facility."

Weinstein said that Gilead, the maker of Truvada, is somewhat complicit in the creation of the black market by aggressively promoting a product that, he believes, should not have been approved as a preventive measure in the first place.

"The whole premise of pre-exposure prophylaxis is dangerous and unwarranted based on study results. In the real world, pre-exposure prophylaxis relies on adherence, which in my opinion cannot be accomplished. People who already have the virus are often noncompliant. What you're going to wind up with is more infections and more resistance."

Dr. Kurtz and Mr. Weinstein have disclosed no relevant financial relationships.

The 7th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention: Abstract MOPE133. Presented July 1, 2013.


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