Opinion split over ‘on demand' drug that reduces risk of HIV

By Clare Wilson Helpful or harmful? A drug that you can take before and after sex can help people cut their risk of HIV infection. Men and women in the US can already take the drug as a daily pill. The new “on demand” regime could make the drug more convenient, and cheaper to use regularly, yet not everyone is convinced. Some doctors fear the approach will discourage condom use, while others, such as Michael Weinstein of AIDS Healthcare Foundation, see it as a free pass to promiscuity. We should abandon such moralising for the sake of public health. “This will be a powerful tool for almost eliminating HIV transmission,” says Cécile Tremblay at the University of Montreal, Canada. “If we combine it with other measures we could reach that goal in developed countries within ten years.” The medicine in question is called Truvada. It contains two antiviral drugs, also given to people infected with HIV, which stop the virus multiplying. Tremblay and her colleagues followed 400 gay men over nine months and showed that the drug reduced risk of infection by 86 per cent when taken just before sex and for two days after, and so was just as effective as the daily pill. On the face of it, having any kind of unprotected sex seems risky. Yet Truvada users are making highly nuanced decisions about their risks, argues Sheena McCormack of University College London, who helped run a trial of daily Truvada. In the West, such pre-exposure prophylaxis, or PrEP, has mainly been studied in gay men. Most trial participants used condoms some of the time, only forgoing them when it seemed safe, after asking their partners when they were last tested and when they’d had unsafe sex (see “Why I don’t always use condoms”, below). PrEP may paradoxically reduce risk-taking in some. “If anything, I probably use condoms more now than I did before,” says Colby Briggs, a project manager at McGill University in Montreal. “Taking Truvada reminds you that you’re not infallible.” One trial of daily Truvada showed that the drug did reduce condom use, yet STD rates stayed the same, perhaps because people were good at assessing their partner’s sexual history. It’s less clear how well PrEP works in people having heterosexual sex. PrEP is not the only tool that we have for reducing the spread of HIV. We could put everyone who has HIV onto antivirals, which can suppress the virus, making it less likely to be passed on. In theory, such universal treatment could eradicate HIV. It’s an expensive goal: the World Health Organization’s aim of suppressing HIV in three-quarters of those infected by 2020 is unlikely to be met. Sub-Saharan Africa and the US have suppressed the virus in 30 per cent of those with HIV; the UK and Australia have reached 60 per cent. Combine universal treatment with PrEP and we could reduce transmission much faster, says Tremblay. Yet access to PrEP is patchy. In the US, where Truvada has been licensed since 2012, a third of doctors have never heard of it. It’s also expensive: in the UK it costs about £400 for 30 pills. Some people are inevitably buying it online for about a tenth of the cost. That’s a false economy for the UK’s National Health Service, says McCormack, because those users may not have the regular HIV tests that are a crucial part of PrEP. If people do get infected on PrEP, their virus can become resistant to the two drugs in Truvada and then spread to others. In many other aspects of HIV prevention, Western countries have embraced “harm reduction”, in other words, accepting risky behaviours cannot always be prevented but can be mitigated. So why can’t we expand that to PrEP? As Tremblay says: “If we have a way to protect people from catching what can be a deadly disease, then it’s immoral not use it.” “I’m not phenomenal with condoms,” says Colby Briggs, a gay man in his twenties who lives in Montreal. “I use them about half the time.” Briggs has taken part in a trial of Truvada, a drug that reduces his risk of contracting HIV. The drug can be taken daily or just before and after sex (see main article). In common with many of the trial participants, his decision whether or not to wear a condom is carefully considered. “I don’t ever have sex with someone who I haven’t asked about their sexual history,” he says. “People are very forthcoming, particularly if they do have HIV. They are often incredibly responsible.” The times that Briggs does use condoms he still uses the drug. “Truvada has never been presented to me as a replacement to condoms,” he says. “It was always an insurance policy. Condoms aren’t perfect, they break, they fall off. This is an extra layer of security.” Journal reference: NEJM, DOI: 10.1056/NEJMoa1506273 Thor Swift/The New York Times/Redux/eyevine More on these topics:
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