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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. 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.


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.

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Read other articles in this spotlight series.

Copyright © 2013 Remedy Health Media, LLC. All rights reserved.
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See Also
Northern Lights

Reader Comments:

Comment by: Jack Motch (New York City) Sun., Sep. 28, 2014 at 11:04 am UTC
Hello, I have been HIV + for over 25 years with the last 7 being full blown AIDS by medical definition. I worked as a care giver in one of the first AIDS hospices in southern cal in 1989 in which they were giving massive doses of AZT and interferon to the patients. After watching them all die within 2 to 3 months of these medical treatments I concluded the drugs were more toxic than the disease its self and suspecting I was HIV + myself decided never to take any meds inless absolutely necessary, I was diagnosed in 1990 and first went on medications briefly in 2002 on a combo containing Kaletra which had awful side effects on me and I had a real crappy mormon doctor at the time so I discontinued the treatment until 2009 when I moved to NYC. By then my t-cell count was 9 and my viral load over 500,000 and I was rather sick to say the least so I started a cocktail with truvada, reyataz and novir which did well with me in terms of side effects and brought my t-cell levels to acceptable and my viral load to undetectable. But! I also know that these meds are very difficult on the kidneys and liver so about a year into treatment I decided to go on to half dosing in which oddly enough everything stayed the same even though my doctors and pharmaceutical companies that were profiting off these recomended dosages were adament in my so called compliance and even threatened to take me off the meds due to so called mutation factors. Fact is mutation occurs taking full dose or half dose as I have many long term surviving friends who have had to change the regimins once every 5 or so years due to the viral mutation produced by full dosing. The difference for me is my liver and kidney tests come back squeeky clean but my full dose friends have all sorts of complications. Fact is doctors and pharmaceutical companies are full of lies and I recomend holding off on any treatment until you really need it and don't be shy to ask questions and learn about your body. Organic foods are best!
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Comment by: Stuck in treatment (S.F. area) Thu., Sep. 4, 2014 at 9:38 pm UTC
Waiting until necessary is a great way to ruin a patient's health. With new drugs that are less toxic than the old drugs, patients can avoid becoming disabled because of the ravages of the disease and the treatment. Anyone that says wait, is frankly an idiot who should never be allowed to treat a patient.
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Comment by: Sunshine (Nairobi, Kenya) Wed., Sep. 18, 2013 at 4:41 am UTC
Insightful article. Just got diagnosed 3 weeks ago. My CD4 count is at 818. I was not given the option of starting meds immediately at all by my clinic (donor funded, so all meds and tests are provided free. I will only be put on meds if my CD4 drops to 350. Treatment as prevention is far from being a reality in my part of the world.
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Comment by: J (New York) Fri., May. 17, 2013 at 6:35 pm UTC
Although prevention is important my health is more important. I started treatment ASAP and I feel fantastic. Isn't there strong evidence and 14 people functionally cured because of early, very early treatment? I can't imagine with all that we know today why anyone would want to delay treatment?
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Comment by: Bob Leahy (Toronto) Tue., May. 21, 2013 at 2:26 pm UTC
There is plenty of evidence that early treatment is good for us, just like it is with many medical conditions. But if people want to jeopardize their health by delaying treatment, while needlessly maintaining high levels of potentially infectious virus in their body, that's their right, and I'll defend that, however unwise that decision seems to me.

Comment by: imstilljosh (Nashville, TN) Fri., May. 17, 2013 at 6:02 pm UTC

I admire your ability to so easily offer insight into your current views and as you already know, admire you personally, tremendously. Although, I am not with you 100% yet (if ever-- I am still attempting to get my hands around this entire debate), this is one of the first articles that I didn't immediately roll my eyes as I was exhausted from propaganda-like talking points almost handwritten, signed and delivered from a talented publicist retained by marketing directives of drugs. Instead, I trust you-- I trust your opinion and value your insight and wisdom; no matter on this one, our degrees of separation.

My best,
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Comment by: Bob Leahy (Toronto) Tue., May. 21, 2013 at 2:18 pm UTC
Josh. I love you for this. Want to get married? :-)

Comment by: Lisa (Philadelphia, PA) Thu., May. 9, 2013 at 6:28 pm UTC
I love your take on empowering those people living with HIV as being able to put an end to the epidemic. Bottom line is that people don't like condoms and time and again will risk contraction/spreading HIV to avoid using them. (As someone previously in a serodisconcordant relationship, I know this first hand!) I am behind anything that is in addition to current strategies. And of course I always support an increase in options. :)
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Comment by: Bob Leahy (Toronto) Sun., May. 12, 2013 at 10:19 pm UTC
Thanks for your supportive comments, Lisa.

Comment by: Matt R. (Kansas City) Sun., Apr. 14, 2013 at 5:19 pm UTC
This is an article from Kansas City about hospitals refusing to treat HIV exposures with PEP.
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Comment by: Bob Leahy (Toronto) Sun., May. 12, 2013 at 10:20 pm UTC
Costly, but cost efficient . .

Comment by: Ken Warnock (Royal Oak, MI) Sun., Apr. 14, 2013 at 3:53 pm UTC

Thanks for your thoughtful insight into your evolution on early treatment of HIV. I was diagnosed HIV+ in 2002 along with AIDS and went on medications almost immediately. My first regimen was Combivir and Sustiva which I tolerated fairly well although the dreams were strange and I suffered GI issues and anemia and was constantly tired. I switched over to Truvada and Sustiva and then to Atripla. I am now on Truvada and Isentress because the efavirenz interacts with another med I am on. I have been a proponent of early treatment for at least a decade now. The studies have confirmed my belief that earlier treatment is better for multiple reasons as you have eloquently described! Keep up the great work!!
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Comment by: Bob Leahy (Toronto) Mon., Apr. 29, 2013 at 4:55 pm UTC
Thank you so much!

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