Are we PrEPared for PrEP?

This article was written by Volunteer Blog Writer Tyler Faulds. Tyler is a student of Mount Royal University who is obtaining his Honours Degree in Psychology. This is Tyler's first article for The AWord. If you are interested in being a writer for The A Word, please visit: http://www.aidscalgary.org/getinvolved/volunteer/volunteeroverview.cfm

Since the introduction of treatment for HIV, the lines have been drawn between medical based approaches and those rooted in social change. The two schools of treatment differ in how they combat HIV and how they foresee an end to the spread of the virus. While medical oriented treatments put heavy emphasis on drug regimens and regular testing, treatments rooted in society and culture believe that change comes through people (Kippax & Stephenson). They often focus on behavioural change and dissect the socio-cultural context of HIV on our planet. Medical approaches can be conceptualized as treatment, and societal ones as prevention. Combined approaches have become more popular, and campaigns that focus on condom use along-side regular testing have been gaining momentum. Still, we see more than 2.6 million new HIV infections a year (Geneva, 2009), and the problem is evidently not under control – yet.

Enter PrEP, or Pre-Exposure Prophylaxis. Considered a medical based approach, this type of treatment involves prescribing HIV negative individuals with HAART as a way to prevent HIV acquisition. It stands as a possible breakthrough in the prevention of new HIV infections, but is also marred with controversy and critics. Approved by the United States’ FDA, Truvada is a combination pill of Tenofovir and Emtricitabine. With perfect adherence in clinical trials, it has shown to reduce the risk of transmission by approximately 40-70% (Okwendu, 2012). These trials evaluated the effectiveness of Truvada within six “high risk” categories including HIV negative men who have sex with men, males and females in relationships where one partner is HIV positive and one is negative, and people that use intravenous drugs. Due to its incredibly high costs (~12 000 USD a year) as well as numerous other factors, PrEP is a highly contentious issue.

The cost alone is a major barrier. While proponents of PrEP suggest that it is applicable to people in higher risk categories, it is evident that cost would be a huge hurdle to cross for some of these groups. In Sub-Saharan Africa, where incomes are low and HIV transmission is high, a $12 000 USD price tag is inconceivable when food is a daily concern. Reactions to this criticism, especially from the drug’s manufacturer Gilead, cite that cost is a concern for any new medical intervention, but through regulation and development the costs would come down.

Salim Karim of the Centre for the AIDS Programme of Research in South Africa, argues that PrEP empowers women. Many must rely on their sexual partners to get tested, get treatment, and wear condoms and that is often a difficult task to accomplish. PrEP would allow women to take their health into their own hands, protecting themselves from HIV with no help needed from others. Opponents argue that relying on PrEP will direct attention away from the heavily needed condom supply and prevention which so many communities still require.

PrEP has been branded a short cut in some arenas. Does it make sense to offer a solution where a person just takes a pill and forgets about it? – they could worry less about safer sex practices, condom use, and needle awareness. Is it that simple? Is it really that black and white? People living with HIV on HAART are all too aware of the possible side effects. Although they differ on a person by person basis, many of them are unpleasant, disruptive and a mountain to overcome. An HIV negative person taking PrEP would not be just taking a pill. They could endure the nausea, diarrhea, and fatigue that accompany the treatment, as well as the kidney damage and bone loss that are hallmarks of Truvada. This is another reason why proponents stress that PrEP is not for everyone. The second part of the shortcut argument is that a widespread use of PrEP (which has been shown to reduce HIV transmission by about 40+%) would change attitudes towards the risks of certain activities and cause people to lax on their diligence and safety. Note - condoms reduce HIV transmission ~90%). Countless studies have asked, “If Truvada or something similar was available to you, and you knew that it would cut your risk of transmission would you still use condoms?” The results have been inconclusive. A study by Golub et al. (2010) showed that 35% of the men they surveyed thought they would decline condom use if on PrEP. Other studies like the one performed by Holt et al. (2012) showed that only 8% of the men they surveyed thought they would reduce condom use. It’s worth knowing that those 8% were also correlated with older age and monogamous relationships.

These answers are likely swayed by the need to answer in a desirable fashion. That is, people will always answer in a way which they think they should rather than how they actually feel. There is no way to tell if people will really stop wearing condoms or using clean needles until actually given the chance. This illustrates why a combined social and medical model is the strongest, because all sides need to be addressed.

One of the largest arguments against PrEP is the issue of adherence. For Truvada to be effective it must be taken every day with no missed doses, and consistently this is not the case. Myers (2012) argues that just like a half-finished bottle of antibiotics following strep throat, an inconsistent adherence schedule would eventually develop resistance to the treatment. This in turn could create strains of HIV resistant to Truvada, a main component of treatment for people already living with HIV. In the pilot study of Truvada, participants were paid for their involvement and also received daily counselling on their medicine adherence. Even still, only 18% of participants adhered to treatment perfectly. If people who are paid and counseled to take a drug cannot do it consistently, how will HIV negative, unpaid and uncounseled individuals fare?

Finally, let’s revisit the side effects. The first antiviral for HIV is not 30 years old, and HAART hasn’t turned 20 yet. There is no denying the ground breaking leaps and bounds that these drugs have provided for those living with HIV. People are living longer and healthier, and the tides may be slowly turning. We know that if treated efficiently and if treatment adherence is high, a person today has a much better outlook than someone 20 years ago did. It might be what we don’t know however, that’s more important.

We still don’t know what will happen after 40 or 50 years on the drugs. What will happen to the virus, to the body or to resistance? There is no data on these risks. We know the drugs are toxic, and is there sense in giving these drugs to anyone other than the people that need them? Should we be putting more effort on social change, or is PrEP really the next step in the battle against HIV and AIDS?

There will always be those that rush ahead, and those that hang back and wait to see what happens. What should happen now? Would you take PrEP if it were an option?

References

Karim S. (2012). Antiretroviral prophylaxis for HIV prevention reaches a key milestone.

Kippax S. & Stephenson N. (2012). Between biomedical and social dimensions of HIV. American Journal of Public Health. 102 (5).

Myers , T. (2012, August 03). Hiv prevention pill will do more harm than good . Retrieved from http://www.usnews.com

Okwundu , Uthman , Okoromah (2012) Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals". Cochrane Database Syst Rev 7 (7)

AIDS Epidemic Update (Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS, 2009).
Golub, Sarit, Kowalczyk, Weinberger and Parsons (2010). Pre-exposure prophylaxis and predicted condom use among high-risk men who have sex with men. Journal of Acquired Immune Deficiency Syndromes. 54(5).
Holt, Murphy, Callander, Ellard, Rosengarten Kippax and de Wit. (2012). Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sexually Transmitted Infections. 88(4).