Guest Opinion: Brave new world: Test, treat, and PrEP

  • by Luke Adams and Race Bannon
  • Wednesday November 2, 2011
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We are both community organizers and spend a lot of time talking with the target populations of the long-awaited New Directions in HIV Prevention in San Francisco. As those changes take shape and the rest of the country looks on to see how we will make them work, we felt that it was time to address some misunderstandings. We also wish to address some reckless and deceptive misinformation in the AIDS Healthcare Foundation's ad campaign against Truvada and in the recent Guest Opinion ["DPH's risk behaviors: A case study," July 28] by Billay Tania and some members of Off the Grid.

Tania argues that the outgoing San Francisco HIV prevention model has proven successful – that HIV has decreased over the last decade, and so he questions the move to a new test-and-treat model. Tania's statistics fail to account for the following discrepancy. In the 1980s and early 1990s, when the "use a condom every time" message was being widely heeded amid the carnage of a barely treatable disease [Catania, 1991], San Francisco went from averaging over 600 to about 300 seroconversions per month [Coates & Collins, 1998]. But as of 2010, evidence tells us (depending on the study [Catania 1991, CDC 2002, Foster et al. 2011, Rosenberg et al. 2011]) that only one-third to one-half of sexually active gay and bi men are using condoms even "frequently." That's in the age of undetectable viral load thanks to effective medications. Yet last year, depending on which set of numbers you use, San Francisco had between 300 and 700 seroconversions all year [SFHIV/HPPC 2011; CDC 2011]. The outgoing model of risk/harm reduction hasn't been an ongoing success; it has been an increasing failure – biomedical science has succeeded far better.

AHF argues that an aggressive test-and-treat strategy regarding all sexually transmitted infections – including HIV and hepatitis-C – and promotion of the pill for negatives (pre-exposure prophylaxis, or PrEP) is "abandoning gay men." This reminds us of the parents in Texas who shrilly oppose giving their daughters the HPV vaccine because "it will make them have sex." We have news for the parents in Texas: your daughters are already having sex and, if they aren't yet, they will. We have news for AHF: people have been voting with their bodies and widely having unprotected intercourse since the mid-1990s.

Let's also take a look at the six points AHF uses in its campaign against Truvada use in PrEP.

AHF disingenuously trumpets the statistic that Truvada was 42 percent effective in the overall iPrex study. However, that was because of the number of persons in the study who did not take the drug every single day as required. In those who stayed on protocol, Truvada was more than 95 percent effective at protecting the HIV-negative partner.

AHF admits that the African studies showed Truvada more effective, but seeks to discount these because the partners knew their serostatuses. In other words, in the African studies, the negative partners really knew they were having sex with positive partners. So why would AHF pretend this is not evidence the drug works?

AHF condemns the researchers on the one hand for not giving them the numbers they want, but on the other hand condemns them for abiding by standard scientific study protocols – you can't have it both ways.

AHF – which treats mostly low-income and uninsured patients – cites in-house self-report surveys in which more than half of their respondents stated they wouldn't want the pill if they had to pay more than $60 a month for lab and doctor visits, or when they heard of possible side effects or possible resistance. The reality is this: Many insurance companies are paying for the viral load lab tests and the Truvada necessary to begin PrEP; there is new federal and pharmaceutical funding for a study to see how many sexually active people will use the pill, and that may portend more public-private funding; and all medications have the possibility of side effects and all antiretrovirals have the possibility of resistance.

AHF, which has used self-reporting to state that people won't want to pay for PrEP, claims that self-reporting is unreliable in the iPrex study when participants talked about additional prevention measures they might be using.

In other words, AHF's six points are a lot of bunk. However, we can agree with AHF about this: There should be further studies about both Truvada and HPTN052 for use in PrEP, and we should keep looking for the most effective HIV prevention medications we can find. In the meantime, we know Truvada can be effective, and the sooner we can get sexually active HIV-negative folks on it, the better.

We now know – because we have seen the evidence – that lowering the community's viral load works. When poz people are stable on medications and have undetectable viral loads, they are over 90 percent less infectious [Pilcher et al, 2004; Wood et al., 2009]. When HIV-negative people go on PrEP, their protection rate greatly increases. We know that people who abuse alcohol and stimulants (coke, crack, speed, ecstasy) are more likely to raise viral load in their own bodies and in the community. We know that not giving intravenous drug users syringe exchange raises the community's viral load. We know that not getting regularly tested and treated for STIs – and by "regularly," we mean at least every three months – raises the community's viral load. We know that many of our new HIV infections come from these subsets, especially the relatively newly infected, unaware that they have a high viral load. But know this: those people standing in line at City Clinic and Magnet and Tenderloin Health and elsewhere every three months to get their tests and, if needed, treatment or referrals, are not to be looked down on; they are the community's heroes!

So what is the socially responsible answer? Some wish to use public health and housing money for 1970s-style consciousness-raising groups. The real-world alternative is to get more people more access to more testing and more treatment (for STIs, HIV, and for alcohol/drug abuse) and more language-appropriate services/case management and, where needed to that end, more housing ( separately for users in recovery – dry, for users who've relapsed but wish to re-track – damp, and for active users – wet). We think the truly progressive answer is the latter.

HIV infections do indeed intersect with some of the difficult needs of San Francisco's vulnerable and marginalized communities. The long-term answer has not been to provide community organizing groups at agencies for these individuals. Historically, without the medical advances we have now, that was all in which DPH could place the public's hope. Today's answer is that, in an age of very limited resources, money for community organizing has to come from elsewhere, and public health and housing monies need to be spent on actual medicine, and on more language-appropriate access and case management for it. We also need new dedicated revenue streams.

Finally, in his guest opinion, Tania asks whether medical professionals will "take on transforming the root causes of HIV." The root cause of HIV-disease is a retrovirus. Progressive social change, in this case, is exactly about empowering people with culturally-useful access to real health care to save their real lives. And that's just what we meant in the 1980s when we were shouting for "drugs into bodies." The Brave New World is here; get with it.

Race Bannon and Luke Adams are longtime community activists. Bannon writes at and Adams is a drug counselor, minister, and MFTI.