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John, stop with the ad-hominem attacks already, you're really not making a case for anything with them. If you sincerely believe that I'm "anti prep" because I'm "anti sex", I can't change your mind, but I do ask that you address what I'm saying on its merits, not what you think I feel. The reality is that it is an unworthy option, a waste of public resources and a potential minefield for public health. I'm opposed to prep because its a bastardization of the patent law system, because its going to result in more infections and because it distracts from the very real needs of those who have HIV, both in the developed and undeveloped world. I'm against prep because it has already demonstrated an unethical tendency towards experimenting on those in the developing world who will never benefit from its implementation, and because the long term manifestations of its rollout will likely be a catastrophic rise in new and resistant infections. In short, prep is the incarnation of everything that is wrong with our commercialized pharmaceutical industry. Finally, prep angers me because it distracts from the only things that will curb this epidemic, a cure or a vaccine. You talk about serodiscordant couples. Read "the swiss statement", or any of the growing body of evidence in its heritage, and understand that any serodiscordant couple conscientious enough to benefit from prep will more likely benefit from the widespread implementation of HAART. Tell me why we're supposed to be drugging the seronegative under these circumstances? You mention partners of "guys who can barely keep it up" as another beneficiary of prep. Since the very notion of condoms inexplicably offends you, I'll refrain from pointing out that female condoms would be an adequate alternative. Instead, I'm going to ask if you honestly believe that impotent, condom averse gentlemen not on treatment are really viable source of transmission? Seriously? Ok, fine, i'll bite. In public health though, the powers that be should always weigh the benefits of something against the downsides. This isn't "anti sex", its common sense, and a premise we are accustomed to in other realms of public health without screaming that people are "anti sex". Thalidomide is a great tool for preventing nausea, but we restrict it under this premise precisely because of its potential to cause birth defects. The five or so infections that may have allegedly been conveyed by these gents in the last decade almost certainly aren't going to stack up against the wave of drug resistance we'll face when prep becomes the hottest sex toy for the DDF bathhouse crowd, or the explosion of infections we'll see amongst those who give up condoms in favor of inconsistent pill usage. Jeton, you make a point about prep being useful to a sub population of users who can remain adherent to an expensive pill, but not a condom. Its a complex arguement peiced together with big words, but it doesn't hold water. I'm inclined to ask who in the real world is going to go in for regular and consistent testing, endure copays of up to $200 a month, take their pills religiously, etc, but won't just use a condom or go in for pep when the time is necessary? You say you're interested in controlling the real world spread of this virus, but I ask you to apply this to a realistic scenario where it will do this, rather than condescend about whether or not I understand Hoffman's meaning of the phrase "sex toy". John tried but came up short. I suspect that your reluctance to do the same is because you fully understand that the number of applicable scenarios are vastly outnumbered by the damage prep will do.
Regan, I totally agree with the points you make and made these same points to the pharmaceutical company at a dinner they put on and advertised as an "HIV and Aging" presentation where they "decided" to change the format to PrEP. I asked where the money for this to be distributed to the people who are mostly in the high risk areas are also those with NO MONEY to pay for it. I work in the HIV prevention arena and find that they have put way to much effort into something which, although it has been proven to work, is not something that people most at risk can afford. And I also agree with your statements about those without HIV being the focus. It is like..if you already have it, we won't treat you but if you don't....let's make sure you have access to something which MAY decrease your chances of getting it....as long as we make money doing that. I don't see the drug companies saying they will provide it for those most at risk for free. As a woman who is living with the disease in a state which has a waiting list and just applied to continue my ADAP, I am frightened that I will not be approved again and know that although I have insurance, I can't pay my co-pays and fear that even with help from the drug companies, I may not be able to continue with my life saving drugs and will have to quit work and school and become one who is living off the system. That is the risk here. If we can't get life saving medications, we will get sick. Then we are not able to contribute to the community in as many ways and we become a burdon. It is about choice...pay now for my copays or pay later for my illness which will inevitably happen. Thanks for standing up and making your voice heard. From the bottom of my heart, I thank you for your unending work to help all of us.
The cost of Truvada PrEP. I just saw a letter in the New England Journal of Medicine of April 7, 2011 in response to the iPrEx trial report. The authors calculate that it would cost $400,000 a year to prevent a single infection. I’m pleased that the calculations in my last post were correct. Truvada PrEP is associated with a very small absolute risk reduction (ARR) of 2.26%. The number of people who need to be treated to prevent one infection was 44 (it’s 1/ARR; I got 45). The authors calculate that treating 44 people will cost $400,000 a year, and this does not even include the costs of regular monitoring. From Sean Strub’s calculations (in his comment to my previous post) which included doctor’s visits and tests, the annual cost would be about $500.000. These figures are based on drug costs in the US. There definitely seems to be a perception that PrEP is for everybody; there even have been calls for its general implementation. These cost estimates alone would make it unfeasible as a public health measure but there are additional reasons, importantly its relatively low efficacy. It's even probable that widespread and uncontrolled use of PrEP could result in an increase in new infections. PrEP is a reasonable option for only a small number of individuals at high risk for infection who are able to be regularly checked for infection. I believe there is no disagreement about this; the controversy is only about its general use. PrEP is not an appropriate public health HIV prevention intervention. I said this in my first post about iPrEx in November 2010 Drs Dong Heun Lee, M.D. and Ole Vielemeyer, M.D of Drexel University College of Medicine in Philadelphia are the authors cited.
I am not poz but had panic attacks from coming close to it. So, I can't know how it really is to be diagnosed. I think this mag is about the greatest good, saving the most lives. So there will be cries of "what about us?" whenever any plan that leaves anyone out comes up. I saw grafitti in a NY subway: "I love GRILS!" then: "It's GIRLS, idiot" then: "What about us GRILS?" It's lives versus pleasure, you can't misspell those.
Andrew, you have reached the limits of your argument. PrEP can effectively lower the rate of infection for people who are adherent to it (most common in the USA) and who don't use condoms...you would seek to punish or brainwash this sub-population towards your point of view, whereas i seek to control the infectiousness of this sub-population. It is precisely the biological parameters of HIV that lead me to support PrEP, as it is well-known that the most infectious spreaders of HIV are those who are both newly infected and participating in highly active sexual networks. it seems many people don't want to hear harangues about condoms anymore...that this surprises anyone at all is telling. some of the Prevention community seems intent on making people fit their prevention models, rather than tailoring those models to real-world behavior. I believe Regan's characterization of PrEP as a "sex toy" is intended to describe PrEP being used to enjoy FULL sexual sensation while also reducing the chance of infection...I haven't the foggiest idea how you could call PrEP a "sex toy" outside the Prevention context. i'd be surprised if you have any idea what you meant by that comment yourself.
Since you asked, Andrew, I'll tell you why I'm so interested in chemoprophylaxis (PEP and PrEP): if it had been available to me, I would not be HIV-positive. Doctors and other health professionals arguing against access to chemoprophylaxis particularly gall me. The fact is that health care professionals have been using chemoprophylaxis to protect themselves from infection for over a decade. They know from first-hand experience that it can be effective. Why is it not available to everyone? Because "it is not cost effective." In other words, it is available to health care professionals because their lives are more valuable than the lives of us ordinary folk (in the opinion of health-care professionals who control access, of course). Is chemoprophylaxis just an expensive sex toy? Clearly some people see it that way. But not everyone can use condoms. What about the 50-something-year-old man who can barely manage to use his penis with the help of vitamin V? How is he supposed to use a condom as well? Not everyone finds sex with condoms satisfying. What about magnetic couples who long for the intimacy of natural sex? Perhaps you find sex with condoms perfectly acceptable - good for you. No one here is arguing against allowing you to have access to condoms. Some have made such arguments; how have you responded to them? You may feel that, in the the aforementioned cases, people should simply accept those limitations on their intimacy, their sexuality and their spiritual satisfaction. That is not your decision to make. Nor should it be the decision of the Regan Hofmanns or even Joseph Sonnabends. Take your anti-sex, anti-choice opinions and use them as your expensive sex toy.
Dear Ms. Regan Hofmann as a Vietnamese newspaper, i've known that u came to VN, Hai Phong, Ngo QUyen Dist., Dong Khe ward. (My hometown). and u had a talk ab HIV and AIDS. i have some questions, if possible, may you spend some few minutes to explain for me. Thanks indeed!. Khanh
Mitch
John, you complain that chemoprophylaxis is used by healthcare professionals to protect them from HIV but withheld from the general public on grounds of cost effectiveness. The type of chemoprophylaxis you reference is Pep, not Prep. No one is disputing that "Pep" should be made available to everyone in need.
August 27, 2011