January 13, 2015 at 12:00 pm EST | by Ray Warren
We already had the pill debate
Truvada, Gilead, gay news, Washington Blade

(Photo courtesy of Gilead)

When PrEP (taking the drug Truvada or another drug to prevent — rather than treat — HIV infection) first became a subject of discussion I was inclined against the idea. But, having listened, read and considered, I’ve changed my mind. Not only does it seem like an acceptable alternative for certain men, it can be a definitive plus for the community as a whole.

One of the keys to my change of heart was the realization that the debate about PrEP very much mirrors the 1960s debate about the birth control pill — something that happened in my lifetime. And once one makes that connection, the arguments against using PrEP for prevention make no more sense than did the arguments about another “pill” several generations ago.

One argument against PrEP is that it does not protect against other sexually transmitted diseases, including highly dangerous hepatitis C. But the same argument could be used against the birth control pill. It offers no protection against STIs (including HIV). That has never been deemed a reason to prevent or discouraging people from using it.

Another argument against PrEP is that anti-HIV drugs have known side effects. But so does the pill. Moreover, when the pill was first approved the side effects were far more severe than with the formulations used today. Some women died from the side effects (strokes, for example) and others faced increased risks of certain cancers and increased blood pressure. Importantly, however, women were allowed to decide for themselves whether the physical and mental risks of an unplanned pregnancy outweighed the risks of the pill. So long as the side effects and risks of PrEP drugs are properly explained there is no reason not to allow individuals the same ability to weight the risks.

Another argument against PrEP is that the touted theoretical effectiveness is not as high as the actual “usage” effectiveness. But there are counter arguments to that contention.

Condoms also only work when used consistently and properly. In fact, the difference between the real world effectiveness of condoms and oral contraceptives in preventing pregnancy is almost entirely due to the differences in adherence and proper usage. In laboratory conditions they both work almost perfectly. Unfortunately, the real world is not a laboratory and condom adherence is not perfect.

In addition, the pill itself only works when taken properly and consistently. It isn’t possible to pop a birth control pill now and then to avoid pregnancy. Public education about that is fact has ensured that women actually do take the pill faithfully, whether or not sexual relations are on the menu for any given day. There is no reason why similar public education could not work with gay men — perhaps using the birth control pill as an illustrative example.

Potential inconsistent adherence does present an issue not present with the birth control pill. Inconsistent adherence to any microbe suppressing drug (whether antibiotics or HIV treatments) increases the risk of inadvertently culturing a resistant strain of the microbe. There is a legitimate fear that inconsistent PrEP adherence could provide a breeding ground for drug resistant strains of HIV.

The “resistance” argument should give us pause. Thousands of people take Truvada and even more depend on other once-a-day formulations that are essentially Truvada with the addition of other drugs. Widespread resistance to the drugs in Truvada (itself a combination of two drugs) would wreak havoc on HIV-positive patients.

But ultimately, the worries about drug resistance should not trump the benefits (both to individuals and the public health) of PrEP. Hundreds of thousands of people already take Truvada or similar formulations as treatment. Widespread resistance has not occurred, despite what must be some cases of inconsistent adherence.

Opposition to PrEP sounds a lot like religious opposition to the pill in the 1960s.  Michael Weinstein of the AIDS Healthcare Foundation fumes that PrEP is a “party drug.” That sounds an awful lot like the dire warnings of preachers that women on the pill would become wanton and promiscuous.

If condoms were the perfect answer to HIV transmission we would not have an HIV epidemic in this country. Clearly, the wondrous theoretical effectiveness of condoms in preventing HIV doesn’t hold up in the real world. People take risks or make mistakes.

We’ve already had the conversation about a pill to prevent an unwanted outcome of sexual intimacy. There is no need to re-invent the wheel.


Ray Warren is the legal counsel for a local government in Northern Virginia. He and his partner live in Arlington.

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