Controversy 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
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?
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.
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.
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.