Is a Pill Enough to Fight HIV?
The New York Times started a debate on Pre-Exposure Prophylaxis (PrEP) for the prevention of HIV infection by asking five prominent researchers and HIV advocates to discuss whether promoting the use of antiviral drugs was a good public health strategy, or if it will encourage more to have unprotected sex.
Beside being over-simplistic, the framing of the question sets the tone, direction and probably outcome of the debate. The question could have been whether PrEP will reduce the number of new HIV infections but instead it sets the intervention against a backdrop of moral and behavioural choices, that of good, responsible worth to be encouraged and supported pubic health interventions (read condoms), versus encouraging bad, irresponsible, reprehensible unprotected sex. Can the two really be part of the same question?
Unsurprisingly, AHF Michael Weinstein, a fierce opponent of PrEP from the start – when little was known about it, embarked on a diatribe based on incorrect facts, stating that PrEP “has failed to protect the majority of men in every clinical trial”. A statement that is both incorrect since the Partners PrEP study showed an 84% efficacy of Truvada among men (P<0.001, not different from that in women) and the CDC Botswana study an 80% efficacy in men (P=0.03); but also a statement that does not make much sense, as it suggests that more than half of the men participating in clinical studies would have been infected during their course (there was 7 infections recorded among 662 male participants in the Partners PrEP study for example).
Whatever the scientific evidences, or that he clearly does not understand research, or that evidence in support of PrEP’s efficacy has been growing since he took a stand, Weinstein prefers to misrepresent and disregard science and PrEP for HIV prevention in favour of the promotion of good old condoms, which “remains the best strategy we have to protect our community” as ongoing rates of new HIV infections demonstrate and which people and particularly young one care to hear about as much as “listening to their elders talk about the “bad old days” resonates about as well as our parents talking about how poor they were during the Great Depression.”
Larry Kramer, who also opposes PrEP, prefers not to deal with the issue of sex, which is a bit odd when discussing the prevention of a sexually transmitted infection. He instead prefers to focus its attention on the long term side effects of the drugs used for PrEP. Though these are real, are they as bad as Kramer says they are? Better ask this question to the thousands of HIV positive people taking Truvada daily or read the reports coming out of clinical studies. But again, who needs evidence when personal anecdotes can fill the gaps.
Both Weinstein and Kramer are out of touch with reality, ignoring evidences, twisting facts and misrepresenting the proposed used of PrEP (which is not for life for instance). It is even questionable that they are aware of who are the current users of PrEP in the US, women.
Thankfully others are focusing their contributions on more burning and relevant issues. Looking forward rather than backward.
Renato Barucco, a public health and LGBT health advocate, acknowledges that “Truvada is not a realistic option for many people at risk, including teenagers and young adults” but accepts that PrEP works, and that “Any prevention tool that limits the spread of H.I.V. in communities at risk has intrinsic value”.
Being aware and acknowledging the limitations of PrEP is key to its successful implementation. In particular that individual adherence is critical to its effectiveness and keeping in mind that scientific and clinical studies have shown time and again that “the protective effect of daily PrEP may exceed 90 percent when used consistently” as Ken Mayer wrote. It will be by pointing at the weaknesses and addressing them that we will build strong and successful prevention programme.
Debating PrEP versus condom is missing the point completely, as PrEP is not for those who use condoms, but for those who do not use them. And what if those who use condoms stop using them because they prefer or want to use PrEP instead? Well, as a number of studies are showing, when taken consistently PrEP works, it works as well as condoms when used consistently (and remember that there are no clinical trial of condom’s effectiveness!)
In a debate with dinosaurs, I find it is interesting to look at the language used by PrEP opponents versus that used by PrEP supporters. The two Wordles below were built using Weinstein and Kramer’s text and then Barucco, Ackworth and Mayer’s text. Two small pictures are worth a thousand words.
What Kramer and Weinstein say about PrEP
What Mayer, Barucco and Ackworth say about PrEP
~rjt
“Debating PrEP versus condom is missing the point completely, as PrEP is not for those who use condoms, but for those who do not use them.”
I would disagree with this assertion since pretty much every write-up re: PrEP is pretty adamant that it is to be used WITH condoms, not INSTEAD of them. While there is undeniably a significant segment of PrEP users that take their pill in lieu of condoms, or are more prone to occasionally/frequently choosing to skip the latex “this time”, there is also a sizable number that continue to use condoms, whether to prevent other STI’s or as a failsafe.
There is an official and institutional approach/wording which consists in saying that PrEP should be used with condoms (the belt and suspenders), and there is a real world approach.
Not every write-up is adamant that PrEP is to be used with condoms, far from it. Many accepts that PrEP will not add much to those who use condom consistently, and that those who use them consistently will continue and should continue doing so – in other words, they would not be good candidates for PrEP, but that PrEP will help those who don’t use them at all, and those who use them irregularly (for a number of reasons, not necessarily because they don’t want to).
PrEP is not to be used in lieu of condoms (but as we know, it may happen). I guess it is in the subtlety of the messages and on a case-by-case assessment: here is PrEP but here are also condoms, even if the provider know they may not be used. Not here is PrEP and you must use condom, because that won’t work.
Condom use should be very much supported and encouraged but the point is that it should not be the only approach promoted when others are available and that prevention should not be exclusive. The bottom line is that an inconsistent condom user will benefit from PrEP because PrEP is a temporary medical intervention, with the added bonus that it will provide an opportunity to promote condoms and their use.
Edited for clarity.