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Dr. Sonnabend, you seem unable to accept the reality that PrEP *IS* an *alternative* to condoms for many. i note your and others' attempts to semantically dance around the issue of who is and is not a candidate. that dance has grown tiresome. once and for all: maintaining or increasing rates of successful and consistent condom usage can only be achieved by focusing on the deficiencies of those devices in the experience of many users. simply attacking PrEP because you fear a bum's rush away from condoms is unsustainable, rear-guard and achieves nothing beyond helping to keep HIV an ever-gayer disease. your widely quoted and disinformational Poz.com posting about "absolute risk" and PrEP remains a profound misrepresentation of the risk faced by very large groups of MSM, and the profound reduction in that risk that can be provided by adherent use of PrEP. Just as you criticize PrEP advocates for "not taking the Real World into account", so too are you guilty of same...your anti-PrEP postings are touted as the Secret Weapon of anti-PrEP trolls roving the Internet and spreading vicious hate, stigma and overt disinformation. the net effect has been an unconscionable obfuscation of the most important new Prevention tool for HIV negative people to use since condoms. all while gay men face ever more apocalyptic infection rates. history will not be kind to you on this. instead of improving a deficient public health strategy of condom-advocacy, you continue to focus on attacking or micro-attacking PrEP. it would be nice if you could just start every article on this with "DISCLAIMER: I HATE CHEMOPROPHYLAXIS."
Like other commenters, I greatly respect Dr. Sonnabend's perspective and wise caution. I see a big source of the problem to be the huge disconnect between the ASOs and PWAs vs. the HIV negative. I feel the HIV crowd including its leadership pushes a pro-barebacking and pro-sero discordant dating agenda. This petrifies HIV negative guys, but since it's not socially acceptable to admit this, everything is swept under the rug. I think PREP is a good choice for HIV-waiting to happen guys who test positive for other STDs. Once the high risk guys are prescribed PREP, the challenge I see is what MDs should do with average joe gay guys-- most new HIV infections are simply dumb luck-- ie. dude thought he was neg etc. A current huge missed opportunity is to aggressively test, treat, and retain in treatment the 50% of HIV poz people who are not being retained in care and not being virally suppressed. Probably would be a more effective strategy than large scale PREP for medium risk guys.
Dr, Sonnabend was the expert in this area in the 1980s. He was right then and is likely now completely right on PrEP in it's current form. 30 years experience should teach us all something. This sounds like the last and best word on PrEP - as it is now being touted.
The problem with PrEP is not one of paucity of information about it, but of paucity of reliable and accurate information about it (on this point, iPrEX Ole added to what iPrEX showed 4 years ago, and 3 other trials in HSX and IDU have also demonstrated efficacy. Pharmacodynamics and kinetics favour better efficacy for gay men). Personally, I have never been a staunch believer of PrEP as an intervention that would make a difference at population level or a supporter of a massive indiscriminate roll out. In this regard I agree with Dr Sonnabend that the WHO could have better formulated and communicated its recommendation - and the media better reported it - and many gay men better research it. But on the other hand I believe that PrEP should by now be part of the options available to Gay men and MSM who are prepared to take it as indicated in a controlled medical environment. It should not necessarily be offered as the first choice to all gay men, but they should not be deprived of it. I do not believe PrEP and condoms are in competition. The opposition to PrEP even among gay men clearly show that it is not the case. As we talk more and more of personalised Medicine, I think we should likewise move towards personalised HIV prevention - and this is where PrEP has a role to play.
I certainly support any individual who chooses to take Truvada PrEP. I was writing about PrEP recommendations and made the distinction between those made to individuals and those made to everyone. I did say that PrEP can be an appropriate individual choice. I was critical of the WHO recommendations which are addressed to all men who have sex with men everywhere in the world. There is more to providing PrEP than writing a prescription. Regular tests for infection, for toxicity and for STIs or support for adherence are not uniformly available, let alone information helpful in assessing the degree of risk in individual circumstances. It's true that the WHO stated that PrEP should be part of a comprehensive prevention package. They were dismayed when papers reported they were advising all gay men to take PrEP without qualification. This dismay speaks to the poor quality of the recommendations. A more thoughtful panel might have taken into account that there is a common perception that PrEP is an alternative to condoms, that the advice to also use condoms is just pro forma, something that can be safely ignored. They should therefore have gone to some lengths to avoid this by emphasizing in the strongest terms that they are definitely not recommending that PrEP be used alone.
I strongly disagree. If you want to take Truvada, do it. I do, and I'm much happier because of it.
I agree with many things Joe says here. We DO need more research. And it's a pipe dream to assume we're going to get more than a handful of people on PrEP worldwide to start with. But there is this polarity he makes between PrEP and traditional prevention inc condoms I simply think is invalid. He says, for instance, that safer sex education still works and we shouldn't abandon it. But PrEP will require just as safer sex education as condoms: is is a variety of safer sex, and we need to get beyond the point where 'safer sex' is solely defined as condoms and their use is the sole measure of social responsibility in gay men. To take PrEP is also an act of social responsibility, of gay citizenship, as witnessed by many of the deeply thouthful testimonies I have read from people considering or starting PrEP. There is no conceivable HIV prevention intervention - even one-offs like circumcision - that won't need to be surrounded by a structure of sexual health education. PrEP is a new tool, not a substitute for helping gay men discuss status, learn about HIV, develop the ability to cultivate rewarding relationships, and pursue pleasure without getting fucked up. Of course PrEP has its own funding, adherence and resource implications as do other prevention methods. But I think it should be a kind of activist 'sin' to place methods that work in implied competition with each other. What works, works, and we need to make sure they work together. One of the things we tried to do with this - www.hivt4p.org - was to find a basic set of standards to unite behind to settle similar arguments about TasP. I would like to see something similar for PrEP.
Frederick Wright
Joe, You have some very good points, although evidence and sex seem to be the mistake in a limited thinking of people and scientist, for truthful evidence might bring to the surface the exact behavior for gays, straights and urban communities, they all like lots of natural sex. Where one group can cover u, the behavior very well to not have any evidence of genital behavior, seemly, and others may have the power to hide the evidence, to be not add-on to the sexual disgrace of their communities imagine, in hiding their head in the sand within the Down Low. So the evidence is either clear or not, does prep work or not. If all the science behind AIDS Inc is built on the viral load theory and is correct, which I think it is flaws in many aspects of science, being made up, in what I call the crystal ball theory of a viral load and in the ongoing experiments with gay men in one death at a time. The shame is that the Gay men are the lab rats to find pieces of a truth, while the rest wait for action, and many dying in the porousness drugs within the Great Human Experiment of Science call AIDS. I suggest with PREP that more information and evidence be broth forth before spending millions, if not billions more in resources to justify the Circuit Party people, The DL People and Leather Community in giving them the green light to go at dogs in heat with their sexual urgencies. Thank you Joe for the wisdom and let’s have a beer in the future, for you are cool in my book. Wink
September 15, 2014