For many of us, the concerns about "treatment as prevention" (using drugs before or after exposure to HIV to prevent infection by the virus as opposed to using drugs after infection to stop it from progressing) isn't about whether or not it is effective on an individual basis in preventing HIV transmission. It is.
The HIV Prevention Trials Network's 052 trial showed a 96 percent reduction in the risk of infecting others among those who took drugs that effectively suppressed the virus. It would have been 100 percent if the trial hadn't included the first few weeks of therapy (when the virus hasn't been adequately suppressed). I can't find a single documented case in the literature where someone who was known for certain to have an undetectable viral load has actually transmitted the virus. If anyone else finds such a case, please let me know.
However, there are very important concerns about treatment as prevention, in particular the pre-exposure prophylaxis concept, (ka PrEP, which is treatment of someone before exposure to HIV with a drug designed to reduce the chance of infection if exposed to the virus). In no particular order:
1) PrEP risks ruining a very effective anti-retroviral by facilitating development of resistant virus, making the epidemic more complicated and more difficult to end.
2) Treatment as prevention strategies are gutting behavioral-based HIV prevention strategies -- like condom distribution, empowerment programs, etc. -- in favor of a bio-medical solution, a chemical treatment to render people with HIV non-infectious.
3) We don't know the long-term effect of taking these treatments and the enthusiasm for treatment as prevention likely will result in many not understanding the risks they're taking when they take these drugs over a long period of time. Ask anyone who has been on Truvada for a few years. If they've had a bone density scan, about half of them have osteopenia and about a quarter have osteoporosis.
4) I question the morality of spending scarce government resources providing treatment for those who don't have an immediate medical need while others are dying for lack of treatment. While I support the right of people to access treatment as they choose, I'm not sure it is the best use of tax dollars to provide treatment to those for whom there is not a demonstrated medical need.
5) Treatment as prevention is highly effective at preventing HIV transmission, but it isn't going to protect from syphilis, the meningitis thingy that's now so scary or lots of other nasty pathogens that are transmitted sexually. That in and of itself isn't a reason to oppose treatment as prevention, but I think this important fact gets lost or overlooked in all the rah-rah over treatment as prevention.
6) Why is there so much enthusiasm for pre-exposure prophylaxis and little discussion, in relative terms, about post-exposure prophylaxis (PEP). The former is an intervention of convenience -- in most cases, not all -- and the latter is by definition an emergency intervention. Any AIDS agency promoting pre-exposure prophylaxis (PrEP) without making a comparable effort to provide ease of access to PEP is, in my view, a bit of a fraud. If they're really focused on preventing HIV, they would start with providing the tools to those who know they are at immediate risk of sero-conversion, either because a condom broke or failed or because they did something they regretted or that afterwards they found out put them at risk.
7) Science has not conclusively demonstrated, with high quality evidence, whether treating people with CD4 counts greater than 500 confers a net benefit or a net harm to the individual. We know it prevents transmission, but what about the health of the person taking the treatment? Are those with high CD4 cells being told that we don't know if this treatment will help them or if it will hurt them? The official recommendation to give treatment to those with high numbers of CD4 cells is based on "expert opinion" of those on the panel -- almost all of the doctors on the panel also have pharma ties -- not on high-quality evidence, or placebo-controlled trials. One could easily identify a group of comparably credentialed scientists and doctors whose expert opinion is that treating people with high CD4 cells is not warranted or not a good idea.
8) Finally, the very name, "treatment as prevention" is offensive to me. What about treatment for those who need it as treatment, not as prevention? It conveys a message that the prevention benefit of treatment is the priority and that's why people with HIV should get access to treatment, to protect those who are negative, rather than to improve our own health.
I think it's the wrong way to address HIV prevention. It's a topic of discussion and debate whether the message is being driven by a drug company pushing to expand its markets, and public health officials whose traditional HIV prevention tools -- sex education, community-based HIV prevention, highly-targeted prevention messaging, etc. -- have been gutted. They're desperate to find whatever way they can to reduce HIV transmission, even if it is a short-term strategy with unknown or risky long-term consequences or that puts other priorities in jeopardy.
We need to look at overall sexual health decision-making, not just HIV.
I couldn't find Steve's commentary online, so I can't speak directly to what he wrote. But the discomfort many feel about treatment as prevention is legitimate and shouldn't be dismissed too quickly. I consider Steve, John and Alex all friends and when it comes to the epidemic, I have never known any of them to act from anything other than their most sincere beliefs.
This blog entry was originally published on WEHOville.