Truvada, the Preventative HIV Drug
by Jen Burd
July 27, 2014
The preventative HIV drug Truvada, one of several HIV pre-exposure prophylaxes (PrEP) endorsed by the World Health Organization and the Centers for Disease control, has renewed discourse surrounding sexual health in the LGBT community. The drug represents a major breakthrough in the decades-long struggle to control the AIDS epidemics, but critics fear that Truvada may encourage some to engage in unprotected sex, spreading other STIs and increasing the danger of HIV contraction among those who take the drug sporadically or not at all.
Two recent studies, the HIV Pre-Exposure Prophylaxis Initiative (iPrEx) and the HIV Pre-Exposure Prophylaxis Initiative Open Label Extension (iPrEx OLE), a continuation of the original study, yielded promising results. The studies were conducted by the San Francisco Department of Public Health. The New England Journal of Medicine published iPrEx's results in November of 2010.
The 2,499 participants were gay men and transgender women, from 11 different sites worldwide, who were at a high risk of contracting HIV. The participants who took Truvada on at least 90% of the days it was prescribed were 73% less likely to contract HIV than those taking a placebo. Researchers created a statistical model based on this data, predicting that when taken daily, Truvada is 99% effective in preventing HIV. Not a single high-adherence participant (one who took Truvada at least four days a week) developed HIV.
In the iPrEx trial, all participants received counseling and regular STI testing and treatment, which contributed to an overall reduction in high-risk behavior such as condomless sex. The OLE study included more focus on the question of whether Truvada encouraged high-risk behavior. Researchers found no correlation between taking Truvada and increased high-risk sex, though those engaging in high-risk behavior were more likely to take Truvada regularly.
Overall, the studies have been remarkably favorable. Preventative treatment is the best possible method for deterring any epidemic, and HIV vaccines exist only in imaginary government vaults in conspiracy theorists' fantasies. Truvada, according to many, is like the birth control pill for AIDS. It has the potential to lift the veil of fear that has been associated with sex in the gay community since the 1980's, provide protection for HIV- people with HIV+ partners, and to save countless lives.
One of PrEP's most prominent detractors is Larry Kramer, an author and co-founder of ACT UP and the Gay Men's Health Crisis organizations. The adaptation of Kramer's play, The Normal Heart, premiered on HBO in May with favorable reviews. In an interview with The New York Times, Kramer told Patrick Healy:
Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There's something to me cowardly about taking Truvada instead of using a condom. You're taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything.Kramer's comments demonstrate a misunderstanding and distrust of the drug that may become a major stumbling block in the way of its widespread implementation. Truvada is intended to provide added protection, not to take the place of condom use. Condoms are not 100% effective. They have been known to break, and even the most well-intentioned don't always use them, or use them correctly.
The side effects that Kramer alluded to, nausea, loss of appetite, and headaches, are mild in HIV- patients, and tend to lessen within the first month of treatment. There is a small risk of kidney damage, but with regular screening, Truvada is perfectly safe. Kramer, however, is not alone in viewing PrEP as a distraction from education and political action. Many gay men who lived through the '80s fear the drug's potential to usher in a more permissive and dangerous attitude toward condomless sex.
HIV is a virus, not a punishment. Human beings have co-existed side-by-side with viruses since the beginning of time, and AIDS will not be last one to devastate a population. Education and activism are essential, but eliminating high-risk sex entirely is no more plausible or desirable than telling everyone to stop sneezing.
Truvada still requires more research and more funding. The iPrEx studies did not include women or men who engaged in heterosexual sex, or intravenous drug users. The long-term effects are not entirely known, though Truvada has been on the market for HIV management for a decade.
At $1,300 a month, the cost of Truvada is prohibitive, particularly for those who need it the most. Young, African-American gay men acquired HIV at twice the rate of other groups in 2010, and they are also less likely to have health insurance. Distrust of pharmaceutical companies and public health initiatives is also an understandable issue in the demographic with parents and grandparents who remember the days of the Tuskegee experiment and forced sterilization.
Still, PrEP treatment represents tremendous progress that was unimaginable 20 years ago. After millennia of trial and error, we were able to eradicate smallpox through the use of preventative technology. People with the tools to protect themselves will use them, and as researchers continue to make incredible strides in AIDS prevention and management, its foothold in the population will weaken.
by Jen Burd
@Skeptoid Media, a 501(c)(3) nonprofit