Hate Condoms? Ethical Choices Now Include Truvada

Pills to prevent HIV are a must if we are to end HIV, hurry up and get on board!                         The article below was first published in the November 2014 issue of OutinPerth.

Hate Condoms? Ethical Choices Now Include Truvada
Striking revelations occurred last month. Two separate studies on the effectiveness of Truvada to prevent HIV were stopped prematurely, because early results were so good that having untreated participants became unethical.

Truvada is a HIV medication currently used to treat people with HIV. Truvada pills are currently being studied in HIV negative participants as a way of preventing HIV infection, this strategy is known as PrEP (Pre Exposure Prophylaxis).

The PROUD trial is the first of the studies to announce to all participants the opportunity to take up PrEP. The study was set up to discover if the benefit of taking Truvada (daily dosing, single pill) by negative guys would be cancelled out by men using condoms less or not at all. So 545 men were randomised into two groups, all participants were offered regular STI testing, condoms, safer sex support and behavioural survey and monitoring. However one group received Truvada immediately and the second group deferred treatment with Truvada by a year. Although the official results of the study are not expected until early 2015 the results were so effective in the Truvada group, that it triggered an ethical threshold set before the study began, now everyone in the study has been offered Truvada for PrEP.

The second trial titled IPERGAY (400 participants) is exciting because instead of daily dosing of Truvada it attempts an “on-demand” strategy for taking Truvada, which is more applicable to the real world. This study set up to discover how effective Truvada would be if you took two pills 24hours before when you thought you were going to have sex or a minimum of 2hours before (e.g. on a Friday for Saturday night sex). Then, a daily single pill dosing while your shagging away (e.g. for some virile men this could last a week), when you think your finished take two final does 24hrs apart. Mmm Lets make this strategy a bit simpler, essentially before you have sex have some Truvada in your blood system, while romping maintain Truvada in your blood system by daily dosing, when your finished dose yourself for another two days. Simpler still, take Truvada 1day before, during and two days after you actually had sex (2+1+1+1). I think overtime the creativity of gay men will finesse this prevention strategy further. Importantly the effectiveness of Truvada in the trial again triggered the study’s ethical threshold and all participants were offered Truvada.

In the US Truvada has already been approved for the purpose of HIV prevention in gay men who are negative. This happened after the iPrEx trial , and subsequently iPrEx OLE trial both demonstrated 100% effectiveness of Truvada in preventing HIV if you had sufficient amounts of Truvada in your blood. This equated to a minimum of taking Truvada (single pill daily dosing) 4 times a week.

What does this mean for Australia gay men? Currently Truvada is legal and can be purchased at penthouse prices privately through your friendly HIV medication prescribing GP. There are some Australian PrEP trials (e.g. VicPrEP) currently underway to confirm the feasibility and science of introducing PrEP in Australia. Participants of PrEP trails get access to Truvada for free. If like Gough Whitlam you believe in free universal health care for everyone then “it’s time” to advocate on behalf of sexually active gay man. We have a right to choose our preferred method of HIV protection. Next time you attend STI testing start demanding access to Truvada.

The business case is also favourable for using Truvada as a strategy in a targeted way. Consider the simple life time cost of treating someone with HIV ( e.g. 40+years multiplied by $15,000 per year for HIV medication) $600,000 times approximately 1000 new infections every year, that’s $600 million potentially added to the PBS every year. Now consider targeted Truvada to the 1% of highly active gay men (e.g. 2200 times $15000 per year) $33million per year. These highly sexually active men would only have to prevent 55 new infections per year for the government to break even on its investment. These inaccurate playful numbers would not stand up against health economist scrutiny, however the maths is accurate enough to make the point that investment in HIV prevention and HIV cure research creates a massive public health return in time.

Preventable infections with targeted Truvada as PrEP could make a significant dent in the Australian HIV epidemic. Given the international science, delays in the introduction of targeted Truvada is not only potentially unethical it could also be described as a material systemic failure of public health policy in Australia. Some people who struggle with condoms and acquire HIV, would every right to become extremely angry at having been denied Truvada as a prevention option.

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