PrEP frenzy!! Get your tenofovir before it's too late!!

Seems like my inbox and all sorts of other HIV-blog-nerds are abuzz lately with dramatic chatter about PrEP. If you're unsure what this latest and greatest acronym means, pre-exposure prophylaxis is basically when HIV negative folks take antiretroviral meds before being exposed to the virus as a way to reduce the likelihood of becoming HIV positive. That could either be for guys not using condoms for whatever reason or as a compliment to condom use and other harm reduction measures.




It seems strange that people are getting worked up about it right now considering that trial studies are ongoing and we have no real evidence that the possible benefits of PrEP at either the individual or population level will outweigh the potential downsides. Those might include:

• Will putting more people on more drugs for longer periods result in increased resistance to HIV meds overall?
• Is it ethical or healthy to put HIV- people on highly toxic drugs as a preventative rather than treatment measure?
• What would it cost to put high risk individuals on what we know to be very expensive drug regimes? Who's going to pay?
• Could it produce competition for affordable meds between HIV+ and HIV- people?
• And probably most importantly, would any PrEP-associated decrease in transmission rates be nullified by people taking more behavioral risks under the assumption that they are less likely to become infected?
  

So many exciting things to wring our hands over in the years ahead!

Actually, it's already started. David Kaufman describes PrEP as "an ideal microcosm of the current debate on health care" in a guest post for The Daily Beast entitled, "The End of Condoms?" He writes:

[F]or the past half-decade, Dr. Conant has been doing something with no outside observation that’s considered blasphemy by many AIDS specialists: he’s prescribing powerful HIV meds to people who don’t have HIV.

...Still unproven—and possibly illegal—PrEP is upending the AIDS world, as it conflicts with the “Always Use Condoms” mantra that’s been at the center of AIDS-prevention strategies since the beginning. But PrEP advocates don’t mind that. They think of themselves as realists in an era where people just aren’t as scared of AIDS as they used to be. “Many of these patients have simply given up condoms, but are still looking for ways to stay negative,” says Dr. Conant of his PrEP users, who are all gay.

Oh dear.

In a pretty great response piece entitled, "The End of Condoms? Not so much.", Trever Hoppe compares David Kaufman's analysis to that of Margaret Wente from the Globe & Mail. Ouch. Hoppe writes:

HIV prevention is a big feild, and there's an ongoing dialogue about PrEP - as well as the whole complex of related issues like safe sex, versus serosorting, versus barebacking, versus social network interventions, versus combination prevention.

So when journalists like David Kaufman and before him (but even more problematically) Margaret Wentes collapse all that discourse into a single dichotomy of opinion, the results are not pretty. Wente's article attacked a nameless, faceless "AIDS establishment", while Kaufman gives us "AIDS world" -- now that sounds like my kind of fun park!"

The Hoppe piece is great because it starts off critical and witty and ends up positive and witty. Yay for light heartedness in PrEP Wars 2009! (And for the record, I thought the Wente article was way dumberer than Kaufman's.)

One PrEP opinion piece that made me think an awful lot recently was written by RawTop, an unapologetic NYC top who chronicles his condom-less adventures on his blog with both written posts and videos. Granted, you'll have to read his piece, "PrEP is a Really Horrible Idea," with a HUGE grain of salt. As one reader points out: "1.) You are not a doctor, so don’t give medical advice; 2.) You are not a psychologist, so don’t give psychological advice; 3.) You are not a drama queen, so leave god out of it." But if you account for all that, it's a pretty fascinating view into how one man who regularly chooses to have high risk sex is thinking about this potential technological advancement in HIV prevention.

Me? I'm still unsure. A friend who thinks about HIV more on the population level suggested PrEP (and its attendant hand wringing) is not so unlike when the birth control pill was new. Assuming we can account for the potential downsides over the coming years, why would we not embrace a new development that can slow down transmission and allow us to have more of the sex we want? I tend to agree, though what makes me nervous personally is the toxicity of the drugs. I guess I'm in an advantageous situation, though, because I don't really crave unprotected anal sex. I've negotiated it with my boyfriend and enjoy that but with casual partners, it just doesn't interest me. So medication-less sex with condoms would probably be the option over medicated condomless sex for a guy like me, then.

Still, there's likely a whole lot more mudslinging debate to endure before society agrees to give any of us that choice. And the first step will be waiting to hear the upcoming results of the PrEP trials...