April 1, 2014
In 2011, when the U.S. Centers for Disease Control and Prevention (CDC) released interim guidance on pre-exposure prophylaxis (PrEP), I was immediately skeptical about the feasibility and pessimistic about the practicality of this intervention. If health care providers won't routinely screen for HIV, how would we convince them to prescribe a prevention pill to healthy people? Furthermore, by embracing this biomedical intervention, I believed the CDC was signaling the eventual abandonment of behavior change interventions. I was deeply disappointed -- until World AIDS Day 2013, when a young, gay man was diagnosed with acute HIV infection at our hospital. His story has forced me to face the reality of PrEP's role as a viable and necessary prevention strategy for people like him.
He came to our emergency department complaining of fever and vague symptoms like profound fatigue and loss of appetite. He had been sick for a week and initially went to a nearby hospital, but was sent home with a flu diagnosis and advised to rest and hydrate. Fortunately, because of our hospital's participation in the HIV FOCUS initiative, we offer 4th generation HIV testing, which led to his diagnosis of acute HIV infection.
His viral load was over one million copies. As he began to recover, he openly discussed with me his sexual history and extensive knowledge about HIV and its treatment. To my surprise, he was even aware of PrEP, but dismissed it as a prevention option because he thought the medication was "out of [his] price point."
He told me about his preference for anonymous sexual encounters without condoms and the lack of communication about HIV status or STI (sexually transmitted infection) history before or after these encounters. Finally, he spoke with clarity about the high likelihood of returning to this behavior once his virus was controlled. As he educated me about the realities of sexual behavior, partner selection and decision-making among many gay men his age, I realized that for some, PrEP is a valid prevention solution.
Many questions are circling about PrEP. Do we have enough efficacy data? How much adherence is enough? Are insurance companies paying for the medication? What are its long-term effects? Who will prescribe it? Will we propagate drug resistance given the limited access to diagnostics for acute HIV infection? The list goes on and on. The questions are valid and many of my own. However, given what I know now, I choose to align my practice with the science and data on hand. We may never fully elucidate the answers to all of the questions posed about PrEP. My patient may be only one, but I am convinced he speaks for many others, which for me means the benefits outweigh the risks.
While not a panacea, I have embraced PrEP as a viable public health intervention and one of the few options we have that could help us achieve an AIDS-free generation. My conversion to PrEP means reconciling this new prevention standard with my deeply held commitment to behavior change as a long-term strategy for reducing HIV morbidity. I remain hopeful that we will not relinquish our obligations to prevent infections through behavior change. However, given my recent education, I am confident that for many like my patient, right now, PrEP may be our best and most immediate solution. I accept that.