October/November #175 : The PrEP Debate - by Reed Vreeland

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October / November 2011

The PrEP Debate

by Reed Vreeland

Pre-exposure prophylaxis, or PrEP, is the practice of people at risk for HIV taking daily doses of antiretroviral medication (ARVs) to reduce their chances of contracting the virus. This summer the conversation around PrEP heated up. While studies suggest PrEP could be an important addition to the HIV prevention tool kit, concerns remain because PrEP’s effectiveness depends on adherence rates that are likely to be different in the real world than in clinical trials. Some worry that people on PrEP won’t get tested regularly for HIV, which could result in their contracting and spreading the virus and possibly developing resistance. There is also the issue of side effects and whether or not those on PrEP will be regularly monitored for them.

Given inadequate global resources, there is an ethical dilemma to consider when choosing to pay for treatment as prevention in HIV-negative people when there are 27.3 million people living with the virus worldwide who are currently not in care. Since ARVs also work as prevention in people with HIV, the argument has been made for emphasizing treatment as prevention in people with HIV; doing so prevents the spread of the virus while saving lives. It is estimated that 45 people need to take PrEP for one year to avoid a single case of new HIV infection; meanwhile, administering ARVs to one person living with HIV could arguably prevent multiple new infections. While PrEP could serve as a powerful harm reduction tool for those at high risk for HIV and don’t have other options, the discussion continues about PrEP’s proper place in the mix.

Below, some recent responses to this hotly debated topic. Join the conversation below.

Chemoprophylaxis—a new word that covers PrEP and treatment as prevention—has probably already helped deprive prevention education of funding. Oral PrEP has no place as a public health intervention. It just does not work well enough. The costs extend far beyond the price of the pills. Since adherence cannot be assured, it’s certainly possible that implementing PrEP as a public health intervention may result in an increase in infections, and some will be with resistant virus.
Joseph Sonnabend, MD, 
New York City

Sure there are scenarios where oral PrEP makes sense, and these scenarios make adding oral PrEP to the HIV prevention tool kit justifiable. But I do not think we should be promoting oral PrEP widely. Let’s spend our energy promoting treatment as prevention for the HIV infected. I think it makes a whole lot more sense.
Eric Sawyer,
 New York City

PrEP will never be used by everyone, or even a majority. But it’s super important for those at very high risk of getting HIV. It could help overcome the biggest weakness of treatment as prevention—the extreme difficulty of getting people with early infection diagnosed and treated in time, when they are highly infectious to others. [PrEP] could do this by [preventing] these people from getting HIV at all.
John S. James, 
Philadelphia

I do not see why anyone would be excited by a 63 percent reduction in the chance of [getting] HIV. This means someone on PrEP takes a [significant] chance at getting infected—not good odds.
Anthony Natif, 
Kampala, Uganda

We must turn the HIV incidence faucet off, and treatment as prevention and PrEP are steps that must be taken—in tandem—to achieve that goal. Let’s do our due diligence and, after the facts are in, embrace new prevention opportunities to reduce new HIV infections and improve the health and well-being of people with HIV.
Ernest Hopkins, San Francisco

I find it astonishing and despicable that all these trials in developing nations are being done given the severe [unlikelihood] that PrEP will be available to those people, especially in light of the fact that at least 10 million HIV-positive people [who need ARVs now] are not receiving treatment.
George Carter, Brooklyn

Search: Pre-exposure prophylaxis, PrEP, Chemoprophylaxis, Joseph Sonnabend, Eric Sawyer


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