Tom Myers is the chief of public affairs and general counsel for the AIDS Healthcare Foundation.
When pre-exposure prophylaxis (PrEP)—the idea of using an existing AIDS drug treatment as an HIV prevention pill—was first introduced, it heralded the promise of allowing people to protect themselves from becoming infected with HIV. Unfortunately for all, this simply will not work the way that scientists and supporters had hoped.
Truvada PrEP will not work on a widespread scale because in order for it to be effective at preventing HIV infection, pills must be taken every single day. No missed doses. However, study after study has shown that people generally cannot meet this ideal.
Even people who are sick, and have the most incentive to take medicine to get better, don't take it as directed. For example, people taking statins for heart disease generally take them properly only 61 percent of the time. When was the last time you finished even a two-week course of antibiotics instead of stopping once you started feeling better?
If we know that people don't take their medicines regularly when they are sick, how can we expect them to take pills when they are not sick? We can't, of course.
In the primary study of PrEP, participants were regularly counseled on taking their pills daily. They had monthly doctor visits, where they again were counseled on taking their medications. Further, they were paid to participate in the study. And yet, even with all this support, only 18 percent of the study participants were taking the pills with any regularity. In the real world, where people don't get paid to take medicine, and where people don't have medication counseling, the results will be even lower. And that's where the danger lies. Not taking Truvada for PrEP properly is more serious than just not having protection from HIV infection.
First, if a person taking Truvada becomes infected, there is a greater chance that their HIV will be resistant to Truvada. Currently, Truvada is the backbone of successful AIDS treatment. The creation of Truvada-resistant strains of HIV is incredibly worrying.
Second, Truvada has serious side effects, including kidney damage and bone loss. These risks may be acceptable when a person has HIV or AIDS, but people taking PrEP are healthy. There will be healthy people who will not get the preventive benefits of PrEP, but who will suffer kidney damage and other harms.
Third, many people, thinking they are protected by taking PrEP, will abandon or reduce the use of other proven preventive measures such as condoms. "Risk compensation," the phenomenon of engaging in more risky behavior when you believe you are protected from harm, has been documented in virtually all areas of life, including the sexual arena. Because many people will not take Truvada properly, but think they are protected, it is entirely likely that widespread use of PrEP will actually increase HIV infections.
The cost of Truvada is over $13,000 per year. For that kind of money, the government, which is the primary payer of AIDS care through Medicaid, Medicare, and the Ryan White CARE Act, could provide treatment for a similar number of people with HIV/AIDS (currently, about 450,000 Americans living with HIV/AIDS lack access to care). Treatment not only makes people healthier and able to take care of their families; treatment itself is up to 96 percent effective in preventing HIV transmission, according to studies.
While I very much wish it would work, I fear that PrEP is one tool in the prevention kit that will do more harm than good.
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