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Prevention, or Profit?
Apr 6, 2006

Hi Dr. Bob! I have written to you a couple of times, and you always provide very insightful answers so I have another question for you. I usually gush about how fantastic you are, etc. etc., but I know youre campaigning for Busiest Man alive, so I will try not to waste any of your precious time! (but you are fantastic!) I have been reading a lot about the new research that shows that Truvada has potential for preventing the transmission of HIV in neggies. At first, I was so excited any news that shows prevention potential is good news, right? but after carefully considering all the facts, I am not so sure how I feel about it any more. I detest the Bush administrations approach to prevention as much as you do, and they have done everything in their power to keep people (especially young kids who come to our clinic to get tested) as ignorant as possible. Equally as deplorable is their unwillingness to spend a tiny fraction of their budget to get HIV meds to people who are the neediest especially when I consider cuts to programs like ADAP and cuts in Ryan White CARE Act funding. Several of the folks that Bush appointed to his AIDS task force have VERY deep ties to big pharma and the companies that they represent - do you see where I am going with this? Now, I think about the future, if this research did prove effective in humans, and I see tons of potential problems namely, expensive drugs that are available only to the wealthy, continued lack of safer-sex based education, and an environment where HIV might become a disease that kills more and more poor people because of a lack of access to these medications. If this medication did become a prevention tool, I also see HUGE profits for a pharmaceutical company at the expense of the lives and well being of my fellow human beings. Am I being a paranoid conspiracy-theory nut? Or would you at least partially agree with these views? We have to work so hard to get meds for our clients now and their lives depend on them! I already harbor deep resentment for the wealthy pharmaceutical companies that rip off poor people and have huge profit margins. In my heart, I know that there are scientists out there working day and night to fight this disease, and I am so grateful for that but I want us to have a cure! Please dont feel pressured to respond, there are a lot of people out there who need help, so I would never begrudge you doing that which you are best at making a difference. Any insight you can provide, though, is appreciated wholeheartedly. Much, much love.

Brian in Texas

Response from Dr. Frascino

Hey Brian,

Another Texan who hates Bush! Wow, that's like the 10th one this week. Things are looking up!

I'll just make a few quick comments about Truvada being used as PrEP (Pre-Exposure Prophylaxis).

1. So far, all we know is that Truvada (Viread + Emtriva) showed promise in preventing HIV infection in six macaques (monkeys). The human trials are just getting started.

2. HIV infects at least 10 people every minute, 5 million every year. Condoms and counseling (inhibited by Bush's policies) certainly have not been enough to slow the spread of the pandemic. A preventative HIV vaccine is still not even on the distant horizon. Clearly we need to investigate all possible effective prevention strategies.

3. Truvada as Pre-Exposure Prophylaxis raises many issues, including significant concerns that PrEP may lead to safe-sex disinhibition and the development of drug-resistant viral strains.

4. The first step is to see if Viread or Truvada (Viread + Emtriva) is safe and effective. These are new drugs and potential side effects/toxicities from long-term use are not yet known.

5. Could this be a windfall for Big Pharma? Certainly. Should we not proceed with the research because of that? No, certainly not. The "generic" cost of Viread is 57 cents and of Truvada, 87 cents. That's more than a condom, but not out of the range of what could be supplied to resource-poor countries with the help of charitable funds and AIDS Service Organization efforts like ours, The Robert James Frascino AIDS Foundation (www.concertedeffort.org).

6. Are you a paranoid conspiracy-theory nut? No, Brian, you are not. But as in all aspects of medicine, we'll need to balance risks versus benefits for any of our interventions.

7. Somewhat worrisome: There are reports of folks already getting Truvada from friends and elsewhere, and using it for PrEP. This could be dangerous, as we are not at all certain how well this will work in humans yet. Nor do we know if it is safe for these horned-up neggies. In New York City, I've heard "V" packs are becoming popular. They contain Valium, Viagra and Viread. This could be a prescription for disaster, rather than a "party vitamin pack."

Brian, I'm sure I'll have much more to say about this topic as the research projects get started and as this story unfolds. The CDC has launched a 19 million-dollar clinical trials program to evaluate Truvada that involves I.V. drug users in Thailand, heterosexuals in Botswana and gay guys in Atlanta and San Francisco. The Family Health Initiative has a study in progress in heterosexual women in Ghana.

So stay tuned, Brian. I'll keep you posted on PEP, PrEP and other prevention news. In the meantime I was encouraged to see that DeLay is quitting Congress. The Hammer is about to be hammered. Karma strikes again. Considering he used to be in the pest-control business, I'm betting he comes back in his next life as a dung beetle.

Stay well, Brian.

Dr. Bob


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