Michael Weinstein, President of AIDS Healthcare Foundation
It seems that gay men are not buying into PrEP.
According to an article posted on AIDSMap.com, a recent “U.S. survey of the prescribing of Truvada (tenofovir/emtricitabine) to HIV-negative people as pre-exposure prophylaxis (PrEP) … found that recipients are more likely to live in the Southern states and are more likely to be female than people receiving Truvada for HIV treatment.”
About a year ago, the FDA approved use of Gilead’s AIDS treatment combination, Truvada, for use as PrEP—a form of HIV prevention. The concept: HIV-negative individuals would take Truvada every day to reduce their chances of becoming infected with HIV.
Then as now, AHF strongly opposed formal FDA approval Truvada as PrEP. Why?
First, let’s make clear that any doctor can write ‘off-label’ prescriptions for Truvada as PrEP to individuals who request it or patients he feels may benefit from its use as prevention—and we respect such use.
Our concerns lay more with what a formal FDA approval could potentially unleash—an aggressive marketing campaign by Gilead lulling unsuspecting gay men and others into a false sense of security about a pill the company’s own research studies show to have marginal efficacy at best.
As it is, in the real world of HIV treatment, drug adherence is very spotty. This is among people who are already infected. A large percentage of patients simply do not take their medications when they are supposed to for whatever reasons.
Given this reality, how likely are uninfected men to take medications every day for the rest of their lives to prevent a possible HIV infection? And if the pre-exposure HIV medication is not at therapeutic levels in their system, they will not be protected.
In a previous Frontiers column, “Giving Up On Gay Men,” I noted that headlines heralding ‘pre-exposure prophylaxis’ to prevent transmission of HIV among gay men were largely applauded by many AIDS experts. The news came in a study of nearly 2,500 men in six countries that found that an average man taking the medication was 44 percent less likely to become infected than a control group taking a placebo.
At that time I wrote, “How very sad that we have come to this point. The applause for this approach shows just how disposable we consider the lives of gay men.”
If we were talking about protecting the general population with a treatment that was only 44 percent effective, would we be celebrating? The 44 percent who received a benefit from the medications were intensively counseled monthly. Blood tests were drawn five times in the first six months of the study. All participants were tested frequently for all manner of sexual infections. This is in no way representative of any real-world situation.
Switch to the real world for a moment. Why would anyone willingly subject himself to such drug therapy every day—therapy with potentially serious side effects—if he had any intention of using condoms?
The use of a pharmaceutical means to prevent HIV infection is based on the premise that we cannot get gay men to use condoms. What is this assumption based on? Have we really made a wholehearted effort to market safer sex in gay-friendly ways? Are condoms readily available in bars and bathhouses? Are condoms advertised on TV? Do our political, religious and community leaders speak out forcefully for protecting gay men from HIV infection? The answer to all these questions is ‘no.’
We cannot give up on gay men using condoms and getting tested regularly.
I applaud efforts to find new ways to prevent HIV transmission. However, small baby steps forward such as PrEP are often interpreted as huge leaps in scientific knowledge. I am heartened that the gay community is wise enough not to have bought into the uncertain promises of PrEP.