A condom in a pill bottle?

Big news lit up the Internet in recent weeks: HIV treatments seem to block the virus from spreading during sex. Researchers from the National Institutes of Health tracked more than 1,700 couples and found that “earlier initiation of (the medicines that fight HIV) led to a 96 percent reduction in HIV transmission to the HIV-uninfected partner.”

How does this work? Anti-HIV medicines interrupt the virus’ ability to multiply inside a person. Scientists suspected that if there’s less HIV in a person it’s less likely that any will leak out in their sexual fluids.

Up until now, most prior studies have traced backwards from outcomes.  Researchers couldn’t be sure if some other cause might have lowered contagion. This time, they enrolled people first then watched what happened when they took medicines.  That makes this study more convincing.

Isn’t this great news in the battle against AIDS?

Don’t flush the condoms yet. It turns out, 97 percent of the couples studied were heterosexual, and half were women. While the protection afforded during straight vaginal sex probably applies to gay anal sex, too, this wasn’t specifically proven.

More importantly, nearly all of the patients studied were living outside the United States. Researchers had “difficulties enrolling (U.S.) participants into the study.” It’s possible that patients in the other countries (Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, and Zimbabwe) were more diligent about taking their medicines than typical Western patients are, because the consequences of HIV are starkly more visible in their homelands.

Unfortunately, HIV is not a forgiving disease; if patients skip more than a few doses the virus roars back. In the U.S. and Europe, patients who start out faithfully taking HIV medications typically backslide after two years on treatment, dropping to take less than three-out-of-four doses on time.

If people skip doses, their virus levels won’t drop enough, and any prevention benefits will disappear. Worse, if they spread HIV now, it will probably be a more deadly, drug resistant virus. A 2002 study found that among people unable to fully control their virus, every tenfold increase in HIV levels made them 81 percent more likely to pass HIV to a partner.

Whether or not HIV medications stop new infections for U.S. gay men, shouldn’t everyone who’s HIV positive take medicines right away, to protect their own health?

Here, things get much murkier. The question about when to start treatment has been debated for years. Delivered at the right time, anti-HIV medications add years, or even decades to life expectancy. But they also often trigger troublesome side effects such as diarrhea, nausea, fatigue, sleep problems, sexual dysfunction, and even hair loss. Over time, their effects on the body’s balances can lead to heart attacks and strokes, liver failure, anemia, diabetes, chronic depression, kidney failure, embarrassing changes in body shape and more. So the rationale has been to spare people these effects, and only start prescribing medicines when they’re truly needed to support life.

The new NIH study may lead physicians to prescribe HIV treatment even earlier than the nation’s guidelines currently recommend.  But it’s not yet entirely clear that the earliest possible treatment lengthens life. It might just add more years of side effects without any net benefit.

Even this week’s study did not find a definite life benefit for those under early treatment. The authors noted, “There were also 23 deaths during the study. Ten occurred in the immediate treatment group and 13 in the deferred treatment group, a difference that did not reach statistical significance.”

The new study raises an ethical question: who is treatment for? If HIV treatment can truly stop the virus from spreading, then shouldn’t it be “forced” on people living with HIV, whether it adds years to their lives or not?  Is treatment supposed to benefit the person living with HIV, or protect the person who might have sex with you?

Unfortunately, very early treatment for the sake of prevention might cause people to “burn through” the best medicines early in their infection, leaving nothing to fall back on when their immune prognosis becomes dire. This would consign those living with HIV to additional years living with complications, and possibly a shorter life expectancy, all in the name of protecting others.

What if the gay community comes to believe that treatment provides the best firewall against infection?  Will guys be less likely to use condoms?  Is the pill bottle a more effective condom?

Pills can’t help when nearly 10 percent of all people newly infected had caught HIV from someone else who was himself also just infected.  During this early phase, the tests often can’t detect HIV.

Medications should be dispensed primarily to benefit people living with a disease, not packaged in a rationale to defend the rest of us from their illness.

Stephen Fallon is the President of Skills4, a healthcare consulting firm that provides services to CDC and HRSA-funded providers, primarily gay- or minority-based agencies and clinics. Reach him via skills4.org.