Here we go again: to PrEP or not to PrEP?
Truvada, the first FDA-approved antiretroviral medication to prevent HIV infection, splits people in fronts: those who are sure that Pre-Exposure Prophylaxis (PrEP) marks the end of the HIV/AIDS epidemic, those who swear the treatment in the long term will worsen HIV incidence in the community, those in between, those who know little to nothing about it and those who simply don't care.
The debate gets unpleasant at times. High profile personalities joined the combative lines.
Author Larry Kramer, public health advocate, vocal LGBT rights activist and co-founder of live saving organizations Gay Men's Health Crisis and ACT UP, did not resort to euphemisms to share his point of view.
Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There's something to me cowardly about taking Truvada instead of using a condom. You're taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything.
Says Mr. Kramer in a recent New York Times interview. Rough, controversial, unafraid, maybe a bit unfair: classic Kramer.
Antagonistically, blogger Andrew Sullivan confronted Mr. Kramer's fiery opinions.
I think of how it might have saved me. I was using condoms after all, and following the rules of safe sex. But I screwed up somewhere along the way, and Truvada would have been a safety net. Why would anyone not want to add that layer of security?
Writes Mr. Sullivan in a post published on his website.
While I'd take Mr. Kramer's rants over other people's snooze fests every day, Mr. Sullivan is right: PrEP saves lives. Particularly, the synergy of biomedical, behavioral and structural interventions, also known as combination approach to HIV prevention, could effectively signify the successful containment of the pandemic.
Consistent and correct condom use is part of combination initiatives. It is also part of PrEP trials and PrEP recommendations. Here's the problem though: The debate around Truvada often becomes a dispute around condom use.
On one side we have anti-PrEP soldiers, Cassandras of super HIV bugs and prophets of untreatable sexual transmitted infections who can come up with all sorts of concerns surrounding unprotected sex. They call their opponents Truvada whores. They often generalize by portraying people on PrEP like a soulless group of sex addicts who crave irresponsible bareback sex with a lot of strangers.
The other court belongs to PrEP crusaders who talk about the extra layer of protection that Truvada offers in addition to condoms -- rightly so -- but, for some reason, end up discussing condom fatigue, talking about the increased intimacy of condom-less sex and about a "new" way to experience sex. They often mention lack of success of condom campaigns and unscientific assertions about how sexually transmitted infections other than HIV can be transmitted even with correct condom use, which, let's be clear, it's an irresponsible simplification. They, too, generalize asserting how all men desire condomless sex and how the other side is simply made of sex negative, frigid, asexual pundits.
For example, Mr. Sullivan writes:
Notice this is about men - not gay men or straight men, but men. You need not ascribe any gay pathology to the reluctance to wear a condom when the consequence is much less dire than it once was. You simply have to be a dude with a d**k.
Considering condom use questionable is problematic.
Both sides of the argument with their extreme positions up hurting their genuine, mutual goal: containing the HIV/AIDS pandemic. Condom use should be a certainty. It should be promoted enthusiastically. Why? Because the people most vulnerable to HIV infection are those who cannot take Truvada at present and probably won't be able to be on PrEP for a long, long time.
Youth aged 13 to 24 accounted for an estimated 26 percent of all new HIV infections in the United States. Teenagers face many challenges while building their identities. It seems unlikely that -- say -- a closeted, 16-year-old gay man will discuss PrEP with his parents, visit his family physician and use his father health insurance to fill a Truvada prescription. It should happen, it may happen, but it isn't happening now. Advocates can surely educate medical providers and parents about the life saving potential of PrEP, but, realistically, this shift in mentality won't happen anytime soon.
Undocumented immigrants, including sex workers, victims of human trafficking and sex exploitations, cannot pay for medical insurance and cannot apply for Madicaid. When they see a doctor, they pay cash for their visit and labs. These folks can only access PrEP by participating in research trials or by relaying on the generosity of patient assistance programs promoted by pharmaceutical companies, which do not pay for medical visits and do not guarantee full, long-term coverage.
Two PrEP studies, FEM PrEP and VOICE 003, showed no significant reduction in HIV acquisition, likely due to poor adherence to the medication. Reasons behind participants' inability to access treatment as prescribed were not studied. What appears to be certain is that a daily pill-taking regimen presents challenges for some populations, especially in territories where access to HIV medication in general is deficient. According to UNAIDS, of the 21.2 million people in Africa eligible for antiretroviral therapy under the 2013 WHO guidelines, only 7.6 million people were receiving HIV treatment as of December 2012. In these territories, people living with the virus meet challenges accessing treatment, let alone HIV negative people who may benefit from PrEP.
What am I trying to saying?
First: leave Truvada alone. Pre-exposure prophylaxis for HIV is effective, live saving and, ultimately, cost effective. More medications are on trials. Possibilities will arise.
Second: leave condoms alone. They are effective, life saving and cost effective, too. Condom use is also the only and easiest line of protection for our youth, our undocumented peers, our disadvantage brothers and sisters worldwide. It's our responsibility to continue promoting condom use. Walk off the condom fatigue; we've been through worse.
Third: Both side of the PrEP debate should take a deep, deep breath.