July 17, 2012
The world is talking about the FDA's approval of Gilead's antiretroviral drug Truvada as a prevention medication against HIV. It is known as pre-exposure prophylaxis (PrEP).
Just a week before the International AIDS Conference opens in Washington, DC AIDS organizations across the US is hailing this as a win in the fight against the spread of HIV. Even the AIDS Foundations of Chicago established a program over a year ago in support of PrEP called Mapping Pathways and also launched a website of videos and written PrEP testimonials My PrEP Experience.
So why am I luke warm? I just hate that I can't ever be a team player. That fact has kept me locked out of sponsorships for sure as well as, big invites to important AIDS events, but I have to call them as I see them. I just don't know how to be any other way. Now be clear I'm not cold, I'm just luke warm. Let me explain.
For sure Truvada is a wonderful medication. Gilead did that thang! As a one pill a day treatment for a-symptomatic persons with HIV it's a miracle pill. It works extremely well in slowing down disease progression and the fact that it's a once a day pill, makes compliance a piece of cake. Over the years the more pills that people with HIV have to take, the more difficult it has been to maintain that regime.
So this is the deal with Truvada as a pre-exposure prophylaxis. Studies in the US show, taken once a day along with condoms and counseling among gay, bisexual and transgender reduces transmission by 42% over counseling and condoms alone. The gay community has long urged approval of Truvada as a way to help reduce this important health issue in the gay community. Click Here
Studies are inconclusive among women and the heterosexual community for the use of Truvada as an HIV prophylaxis. Here's the FDA News Brief.
Don't get me wrong, I think there is some value in Truvada PrEP. I don't want the gay community to say I'm gay bashing. If they think it's one good route of many to prevention in their community then great. But there are a lot of unanswered questions and yes Gilead is trying to put in the necessary follow-up but the fact still remains that there is still a 58% chance that a person will become infected for not complying while taking Truvada.
Given this fact, we have to consider, drug resistance that occurs in newly infected persons while on Truvada and what that does to increase drug resistant HIV. I believe drug resistant HIV is your worst fate, because it limits what will help your strain of HIV.
Then there is the issue that no one really talks about. The long term impact of taking these toxic drugs. Understand something, persons will be taking this toxic medication daily. My doctor who has been treating and doing research on women and HIV since the early days have had conversations with me, about the lack of knowledge of what these medications have done to the body for old timers like me and I've been taking HIV medication for over 20 years. We wonder if all the GI issues I'm having now are somehow related to long term use of those medications. No one has really studied the long term use and with approval of HIV medications at a faster rate than other medications, only time will tell. It really does become a watch and see.
Also, does PrEP give people a blank check to have sex without a condom? We have to be honest about past behaviors in the gay community that led to the spread of HIV in the early 80's and 90's. Even in the 21st century with everything we know and understand about HIV, there has been a sub-culture in the gay community where bareback parties have flourished. Still today men who have sex with men are the largest group of new infections in the US. Ironically this is the same argument for the approval of Truvada. So it's a two edged sword.
If condom studies consistently show when used correctly it will prevent the spread of HIV, then why isn't that the focus? The fact of the matter is people don't use them. Will this be a ticket to never use them? Will it make it easier to rationalize not using them?
And what then do we do about other sexually transmitted diseases such as HPV and Hepatitis which has also been an issue among men who have sex with men. We will see a spike in these STD's without condom use. If we don't change the mind set, how are we going to change behavior?
I know in my own life, I've had men willing to have sex with me without a condom because they know the transmission is lower female to male. And now with the recent advancements of treatment i.e., it's a 2% chance that I will infect someone if I'm on my medication and my viral load is non-detectable, it has helped to foster the mentality that condom use is not necessary . The fact of the matter is, shit happens. The question is how much shit will happen on our watch? My policy, no condom, no sex.
While I see value in Truvada PrEP, especially among sex workers, and women in developing countries, there are too many unanswered questions for general use.
Another thing, do we provide HIV medication to HIV negative persons when those who are living with the disease don't have access? At a price tag of $1000 a month ,who then has access? Will poor black gay men have the same access? Does this become a prevention method for the wealthy? There are a lot of moral questions involved in this topic for sure.
I get it, the AIDS community, especially those on the front lines in the gay community want to decrease new infections by any means necessary, but sometimes, any means comes back to bite us in the ass. There are consequences for everything we do in life. I cannot image that Truvada used as PrEP won't have them. The question is the weight and which way the scale leans in the end. Would the damage done be worth the damage prevented?
I don't have the answers, but I'm not confused, these questions must be asked. I have too many people Tweeting me daily about these issues. God forbid that they misunderstand one of these articles praising PrEP. We have a hard time already trying to convince people that people like me and Magic Johnson with HIV that look healthy with a non detectable viral load still have HIV.
There is NO cure, only treatment. The best prevention is NO sex and No sharing of needles but in this world these will never be a real solution. Our next best is condom use and needle exchange programs. If we can give intensive education on Truvada and the importance of compliance, then why isn't this the same for condom use?
I wonder, if those on Truvada in the study who complied were going to comply anyway, i.e., use a condom whether with Truvada or without? So then does Truvada become a back up for shit happens, just in case the condom breaks? Does Truvada become your back up to fuck when and where and with who you chose? If so, then we are only going back from where we came, just a different route.
Grandmama use to say, "Ain't a damn thing free. In the end we pay for everything we get." There is no quick fix to HIV prevention. The best case is to go get tested, know your HIV status, know your partners HIV status and use a fucking condom.
I am neither a doctor nor a scientist, and I know some could probably take me to task on my position. I also know my opinion will not be popular. But I've come to terms with the fact that I'm a maverick. Truvada is NOT a quick fix, it is only one more thing to add to the prevention strategy, but be clear, this will not come without its own set of problems. I may be dead and gone when the ramifications are made clear. It will take time. Just like it took HIV to spread, but when it did it was like wildflowers.