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Changing My Mind on Treatment as Prevention

April 12, 2013

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6. It's unethical to put public health interests ahead of patient interests by promoting the need to get viral load down at the population level.

First of all, I love that there is an ethical component to this debate; more on that later. But I wouldn't deny there is certainly meat in the above argument. PositiveLite.com writer Ken Monteith recently said:

I do believe that a person can validly choose to embark on treatment early, but not in a context where the background information is being manipulated for another purpose. Treatment guidelines are supposed to be about the health of the person being treated, not a pharmaceutical control of that person's sexuality.

He's right of course. We need to be vigilant that that doesn't happen. Certainly treatment as prevention advocates, including Montaner in particular, stress that the decision when to start treatment has dual benefits -- better clinical outcomes and reduced ability to pass on the virus to others. We need to make sure, though, that the health of the individual is paramount. I believe we as a community are up to that task.

And finally ...

7. Treatment as prevention doesn't work.

Sure it does at the individual level. On that the verdict is in. But at the population level? Certainly San Francisco, the province of British Columbia and some locales in Africa have claimed success in the form of reducing numbers of new infections. The problem is that treatment as prevention, on a population basis, doesn't seem to be working in gay men.

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There has been much debate about why, some of it anatomically based and frankly, in this writer's opinion, bordering on the ridiculous. The saner consensus that seems to have emerged, though, is that because MSM infection rates are already very high, including in the untested, existing treatment coverage (just 28% in the States, with a similar figure estimated for Canada) testing/early treatment at existing levels is just not enough to bring infection rates down. I buy that, which is why I also buy in to the concept of moving people, wherever possible, along the treatment cascade, a cycle which encompasses detection through to viral suppression that's outlined here, as handily as we can.

When it comes to MSM, it's interesting that only some of the more progressive gay men's sexual health initiatives have really brought in to the concept of treatment as prevention. ACON, for instance, out of New South Wales, is a leader in promoting both testing and early treatment with an aggressive (some will say overly aggressive) target of getting 90% of gay men on treatment. The language may be too strong for some but it's beginning to look like these sorts of high levels are necessary to end the epidemic. Certainly this is what the Brits are saying too.

Other organizations, particularly in Canada, are less than enthusiastic. There is, for instance, a position paper from the Toronto PWA Foundation from 2010 that you can read here which is complete as to all possible objections to treatment as prevention, but which provides less attention to its benefits. I would like to have seen more balance here.

And there is the rub, isn't it? Deciding whether new technologies such as treatment as prevention including PrEP -- even home testing -- are to be supported involves weighing the pros and cons, not looking merely at one side of the scale. And in the changing environment in which we live, I've come to believe that in the last year or two the scales have been tipped in favor of looking at treatment as prevention, both at the individual and populations levels, as something to be embraced.

Many have made the point, though, that treatment as prevention needs to work in tandem with other prevention technologies and condoms in particular. They are right, of course. Let's not go overboard here. HIV-negative people in particular need to be encouraged to use them. Positive folks who are undetectable? The verdict is still out, but I'll wager that it will come to pass that it's not just between heterosexual discordant couples where one is undetectable that the chances of transmitting the virus are close to zero.

In any event, you know where I stand now. Know too that in Ontario it sometimes feels lonely to be a proponent of treatment as prevention, but I'm OK with that. Besides, group think has never been a virtue I've bought in to.

One final argument for treatment as prevention I'll throw in, and it's an ethical one we seldom hear because, well, we seldom talk ethics. But here's the thing. Our community has had an amazing record of grappling with the epidemic from within. That's because we care for each other. We understand community. So we promoted condom use, for instance, when condoms were just a birth control device, even when we didn't like them. We created an amazing community-based health infrastructure that has become a model for others. Now we have a chance to end the epidemic -- again from within. And people living with HIV now have the power to make that happen.

As I said earlier, it's become patently clear that existing prevention strategies aren't cutting it, unless you call containing the epidemic, some of the time, a success. I don't. For the first time in years, there is a pathway to perhaps end the epidemic but it involves, among other things, people living with HIV actively participating. That strikes me as a huge opportunity rather than a threat.

I for one would love to see us seize that opportunity. Why? Many reasons, as you'll see above, but on top of all these -- and here comes that ethical thing again -- is that I now believe it's the right thing to do. That's not so strange, is it?

So what do you think is the right thing to do?

Send Bob an e-mail.

Read Bob's blog, Northern Lights.

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Read other articles in this spotlight series.


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