I think the most compelling part of Regan's blog ("Not Drinking the PrEP Kool-AIDS") is her comparison of the recent PrEP studies to HPTN 052 - which I think is unquestionably on the money and it clearly shows that the way forward to get the HIV epidemic under control is to de-stigmatize HIV, normalize testing, rapidly scale up test and treat, and scale up/roll out better first line treatments universally.
This paragraph says it clearly:
HPTN 052 suggests that if we could achieve universal testing and access to care for all people living with HIV, we could reduce individual viral loads around the world and therefore lower the global "community viral load." By doing so, we could reduce the overall potential HIV transmission risk around the world significantly. If we could test and treat every positive person--and, admittedly, there are many significant issues to address in order to make universal access feasible, not the least of which is the challenge of paying for ARVs for tens of millions of people for the rest of their lives or until there is a cure--would we really need PrEP? Would we really need to give medications to people who don't have a disease?
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 -- as it is already is being promoted -- as it is driving people to MDs offices in NY to request "the pill to prevent HIV" and (this is according to a friend who is an HIV MD) having them ask telling questions like: "Oh insurance won't pay for it and it's so expense - I can't afford that every month - since I usually only have sex on weekends - can I just take it Friday and Saturday nights?"
If someone did a study that showed a shot/a pill of penicillin before having sex with ten people infected with "the clap" resulted in a 63% less likelihood to catch gonorrhea, would we be promoting daily penicillin shots/pills as an intervention to prevent transmission of gonorrhea? I think not.
I believe we need to promote campaigns to de-stigmatize HIV, promote the normalization of HIV testing, rapidly scale up test and treat, and aggressive scale up/roll out better first line treatments universally and make the point to governments that you can pay now to get HIV under control and stop transmission while treating those already infected (through wide spread roll out of test and treat); or you can continue to treat only part of those HIV infected and let those not on treatment (many of whom do not know they are infected) continue to infect others, creating an ever expanding number of HIV infected people and an ever increasing financial burden on the health care budgets.
Let's spend our energy promoting treatment as prevention for the HIV infected, I think it makes a whole lot more sense.
(This is my personal opinion and not the position of any organizations I have founded or work for.)