December 21, 2015
By David Kaufman
Despite the news blip provided by Charlie Sheen, it has become all too easy to stop thinking about AIDS and HIV.
But that would be a mistake. Because right now, an unlikely alliance between global drug makers and local politicos is recalibrating long-term HIV prevention strategies across New York state — and the entire nation.
And not necessarily for the better.
At the center of these efforts sits PrEP — the HIV-prevention regimen that uses the antiretroviral medication Truvada, to keep people without HIV from acquiring the virus. Initially, drugs like Truvada were developed to manage the disease in folks with HIV; Sheen, for instance, takes antiretrovirals to remain healthy and alive.
But extensive research also demonstrated antiretrovirals’ ability to prevent new HIV infections from happening in the first place — prompting the FDA to approve Truvada for general use in July 2012.
Any method proven to reduce HIV transmission is worth celebrating, of course; the disease has killed over 35 million people worldwide. And the science around Truvada is clear: When taken as directed and monitored by physicians, most users remain HIV-free. Less clear, however, are the policy decisions — and societal implications — resulting from Truvada’s introduction into the general public.
Back in 2009, I wrote one of the first major-media articles about PrEP and its then-uncertain future for The Daily Beast. At that time, well before its FDA approval, everyone from HIV activists to then-White House AIDS “czar” Jeffrey S. Crowley insisted that PrEP would remain at the fringes of established HIV-prevention strategies. If approved by the FDA, they said, PrEP would only be used among a small cohort of vulnerable “at risk” populations — never as a mainstream magic bullet.
But this is exactly what is happening. Over the past year, Gov. Cuomo has released a series of large-scale anti-HIV programs intended to end the epidemic by 2020. Noble in their ambition and scalable to national levels, the schemes — which are budgeted in the hundreds of millions of dollars — feature everything from increased HIV testing and treatment to improved social services and public housing to end new infections in the next five years.
The programs’ most contentious components, however, center around PrEP — which has seemingly supplanted condom use as the state’s most important prevention method. Albany’s strategy is clear: “Ending the Epidemic (ETE) in New York State will maximize the availability of life-saving, transmission-interrupting treatment for HIV,”according to the program’s 70-page “blueprint.”
And this means dramatically expanding the promotion and availability of PrEP as the primary tool for preventing new infections.
Sure, condoms are also sprinkled throughout that “blueprint.” But unlike PrEP, not once are they presented as the front-line prevention technique they’ve served as for decades. Instead, as Albany sees it, popping a pill — rather than rolling on a rubber — is the key to eliminating new HIV cases, particularly among the most at-risk populations, like young people and minorities.
Indeed, PrEP is repeatedly positioned before condoms in New York City’s youthful new“Play Sure” ad campaign featured on subways citywide. And pop culture has also picked up on PrEP, which has served as recent plotlines on TV dramas such as HBO’s “Looking” and ABC’s “How to Get Away With Murder.”
It’s clearly working: Millennial gay men now blithely — and proudly — announce their antiretroviral use much like Gen-Xers once declared themselves antidepressant early-adopters. Except PrEP isn’t Prozac — and preventing HIV is far more complex than tackling a case of the post-adolescent blues.
What we know about PrEP is this: It works and it works well — so well that studies in San Francisco confirm PrEP’s role in helping reduce new HIV cases to record city lows. But there’s just too much unknown about PrEP for New York state and city officials to make it the anchor of ending the HIV epidemic.
Initial data does suggest PrEP has relatively few immediate side effects. But that data is barely five years old — and extensive research documents the inevitable damage long-term antiretroviral use has on the body. What’s more, those same San Francisco success studies also indicate a decline in condom use along with a worrisome rise in sexually transmitted diseases in folks taking PrEP, including serious conditions like syphilis.
Beyond questions of science, PrEP ultimately comes down to a question of sense: Where is the logic in prescribing a medication to prevent a disease that must ultimately be treated with the exact same medication?
PrEP advocates say that users can go on and off of it as needed — dropping the pills for condoms or other safer-sex methods. But if generations raised on rubbers now find it difficult to maintain condom adherence, how can we expect this next generation to be cautious if they’re never encouraged to use condoms in the first place?
As with many progressive causes, PrEP advocates are aggressively intolerant of critique or dissent. Folks challenging PrEP on a policy level are quickly branded “denialists,”while those critiquing its cultural consequences are accused of “shaming” PrEP users.
Nonsense. Questioning PrEP’s sudden prominence doesn’t deny its effectiveness or judge those taking it. In fact, with a cure for HIV still nowhere to be found, PrEP must have a key role in conquering the virus. The only denial is insisting that role is the only method at our disposal.