Mosquitoes don’t discriminate, I do
There’s a lot of really exciting news coming out about Pre-Exposure Prophylaxis (PrEP) for HIV prevention. We’ve already gotten exciting news about Post-Exposure Prophylaxis (PEP) that Sarah Palin famously failed to provide for rape survivors in
Alaska. If PrEP is as effective as everyone thinks it may be, it could be huge.
Let’s work through some issues.
1. Availability of PEP has not drastically changed the way we do HIV prevention (yet). Still need testing, condoms, and ART; not a magic bullet.
2. Availability of ART has changed the dynamic of the epidemic in some ways. Some people take more risks after being on treatment, but this is a relatively small part of the population. (I learned about the MTV combo today – Meth, Tenofavir, Viagra – sounds like a big night!)
3. PrEP is not going to be like a statin or the pill, other than the fact that people at risk for
{HIV, pregnancy, high blood pressure/cholesterol} can take a pill everyday to mitigate some of their risk.
3a. Stigma: a non-issue with statins. An issue with the pill depending on your relationship and where you are. A huge issue with PrEP – what if your partner found out you were taking it? (“…Awkward!”) I’ll come back to this.
4. Who do we give PrEP to? … I really have no idea.
4a. Discussions are around MSM and African-Americans. Lower on my totem pole of concerns is that this *may* fuel (groundless) conspiracy theories that the government is behind AIDS. What happens when/if something goes wrong? Higher on my list is who we leave out by targeting only high risk groups.
4b. See 3a. When/If we give it to women, and her partner finds out she’s taking it, violence will ensue.
5. Does PrEP increase risky behavior? Trials in West Africa indicate it “does not decrease condom use.” I read this as “no significant difference in reported condom use pre/post.” Even if they are looking at condoms bought/taken from public clinics or private pharmacies, I bet those numbers are tiny. In my experience (working on family planning in Ghana) condoms were not that popular – because it introduced the idea that one partner could catch something “somewhere else” and bring it back. She didn’t want to seem distrustful, he didn’t want to be accused of cheating. Relationships are complex and power dynamics are tough. I think we’ve got a long way to go in the area of gender dynamics before PrEP becomes a viable prevention solution.
6. So do I take PrEP if I’m partying tonight? Someone equated it to taking malaria prophylaxis before traveling to endemic areas, and I’m going to have to disagree. I doubt people plan unprotected sex acts the same way they plan trips to third world countries. Mosquitoes don’t discriminate when they bite, but people should if they’re having sex. See 3a. I’m back to stigma, stigma, stigma.
7. Similar to issues in malaria with choloroquine resistance and now, the way ACT is failing, as chemoprophylaxis becomes available for HIV, it only facilitates the rise of resistant strains. If it gets worse than what we can handle with ART, we’ve got bigger issues.
Keep your ears open, there will be a lot more to come on this topic.
