PreP: Best Shot We Have

truvadaControversy continues to swirl around PreP (Pre-Exposure Prophylaxis). On the one hand we have the simplistic enthusiasm of the Fuck Raw Now posters that appeared in Melbourne recently. Others are urging caution, because throwing away the condoms in favour of the pills – which is what people are doing – brings up a whole range of new (and some very old) problems.

The Clap Is Back

pic: Eric E Castro

PreP – taking anti-HIV drugs while well, so as to stop the virus getting a foothold in your body – will only protect you against HIV. Condoms, meanwhile, help stop you from catching syphilis, gonorrhoea, chlamydia, and a host of other sexually transmitted infections, including HIV.

So if everybody ditches condom and relies solely on PreP, more people will catch syphilis etc. This is true. But does it matter? And anyway, it’s already happening. These diseases are already on the rise: people have already ditched condoms. Check out Grindr, Scruff – this horse has already bolted.

By and large, these diseases are curable. This was exactly the situation before HIV came along, and we managed. Science is already working on the answer: a pill to prevent other STIs as well as HIV

Is Truvada 100% effective as PreP?

Depends a) who you ask and b) what you mean by effective. This study says yes, but

Of the 657 individuals in the study who actually went on PrEP there were NO HIV infections.

But: after 12 months of PrEP use, 50% of the PrEP users were diagnosed with an STD: 33% with a rectal STI (sexually-transmitted infection), 33% with chlamydia, 28% with gonorrhoea and 5.5% with syphilis.

And to be fully effective it must be taken continuously

HIV stats will rise again

So without easy access to PreP, with condoms are being abandoned, more people are becoming infected. Getting To Zero by 2020 looks unattainable.

It Will Create Drug Resistant Strains of HIV

Again, yes and no. Some people who started PreP not knowing they were already infected with HIV, did develop strains that were resistant to ONE of the drugs in Truvada (that means it’s very important not to start PreP without first knowing your status). However, these resistant strains are treatable with other anti-retroviral drugs. And then there’s this to consider:

Seroconversions on PrEP are more likely to occur during penile/vaginal sex than during anal sex, which helps explain why drug resistance developing during PrEP hasn’t been observed in groups of MSM and trans women who have seroconverted after receiving PrEP.

Still worried? The Journal of Infectious Diseases points out that:

Concerns about drug resistance were raised before rolling out widespread antiretroviral therapy in Africa, based on the assumption that adherence to therapy would be poor and drug resistance would become prevalent. Defying expectations, the benefits of antiretroviral therapy for improving health, averting death, and preventing transmission were subsequently proven to outweigh the risks of drug resistance…

PreP doesn’t prevent HIV-2 infection, only HIV-1

Again, it’s both yes and no.

The National Institute for Health (USA) says 

HIV-2 is intrinsically resistant to non-nucleoside reverse transcriptase inhibitors and to enfuvirtide; thus, these drugs should not be included in an antiretroviral regimen for an HIV-2 infected patient.

The constituents of Truvada are nucleoside reverse transcriptor inhibitors: HIV-2 is not resistant to them. However, resistance may develop: again, testing before treating is vital.

Resistance-associated viral mutations to nucleoside reverse transcriptase inhibitors, protease inhibitors, and/or integrase strand transfer inhibitors may develop in HIV-2 infected patients while on therapy. However, no validated HIV-2 genotypic or phenotypic antiretroviral resistance assays are available for clinical use.

It’s Time

Larry Kramer, founder of ACT-UP. pic: David Shankbone

Whatever the concerns, the case for universal PreP NOW is compelling. Even veteran AIDS activist Larry Kramer, previously vehemently opposed, is now on board.

So what’s the delay? The current cost to the taxpayer of $10,000 per patient per year is unpalatable to a conservative government. This is why we’re hearing all this stuff about providing it only to high-risk people, like those in serodiscordant relationships.

Someone, somewhere, deep in the bowels of Canberra, has done a cold calculation: the cost of lifetime treatment of all those young gay men infected between now and 2017 (when Truvada comes off patent), will be less than the cost of providing subsidised PreP now.

Cheaper generic versions will be available in 2017 at the earliest. The government will not, in the meantime, purchase generic supplies. The AIDS Councils will not run “Dallas Buyers Clubs” to import cheap generics. As discussed elsewhere, you can ask your GP for a scrip and buy the generic version yourself over the net from Africa, if you can afford it.

Meanwhile the Victorian AIDS sector have cobbled together an Accord, with a cheery “Don’t Worry, We’re Working On It” message.  So that’s alright then.

About the author

Veteran gay writer and speaker, Doug was one of the founders of the UKs pioneering GLBTI newspaper Gay News (1972) , and of the second, Gay Week, and is a former Features Editor of Him International. He presented news and current affairs on JOY 94.9 FM Melbourne for more than ten years. "Doug is revered, feared and reviled in equal quantities, at times dividing people with his journalistic wrath. Yet there is no doubt this grandpa-esque bear keeps everyone abreast of anything and everything LGBT across the globe." (Daniel Witthaus, "Beyond Priscilla", Clouds of Magellan, Melbourne, 2014)