True blue?

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01 Dec 2014

Depending on who you listen to, Truvada is either a miracle pill potentially capable of ending HIV or a party drug likely to lead to bacchanalian behaviour. Not since “the pill” has one tablet caused such a divide in opinion.

The controversy surrounding Truvada (a medicine used to treat people with HIV) began two years ago when the drug was approved as a pre-exposure prophylaxis (PrEP) in the United States — meaning the tablet could be taken as a precaution against contracting HIV.

Michael Weinstein, president of the AIDS Healthcare Foundation in Los Angeles, was among the first to describe Truvada as a "party drug" (the suggestion being people will take it before or after a "big weekend" thinking this will provide protection against condomless sex).

PrEP has been shown to reduce the risk of HIV infection by up to 99%. But to achieve such a high level of protection Truvada needs to be taken every day. Damien Rivkin, a clinical psychologist at Sydney’s Albion Street Centre, says such strict adherence is a concern.

“PrEP is far more demanding than using condoms. It requires more discipline,” said Rivkin. “It's hard enough to get positive people to take their meds every day. It would be harder to get negative people to take their tablet every day in the off-chance that they might have sex."

Earlier this year, America’s Centres for Disease Control issued PrEP guidelines. They state that PrEP is for people at “substantial risk” of HIV infection such as gay men, people who inject drugs, or negative partners in poz/neg relationships. Authorities in San Francisco have since made Truvada available to those eligible, and New York is considering doing the same.

Opponents of PrEP say its availability will discourage condom use. Yet there is no evidence in the US of PrEP users abandoning condoms en masse. Besides, Australian studies already show increasing numbers of gay men aren't using a condom every time they have sex.

Some clinicians are also worried that should PrEP encourage people to have a lot of condomless sex with multiple partners they risk picking up sexually transmitted infections (STIs) such as gonorrhoea or syphilis — which can in turn cause a positive partner's viral load to rise and increase the chance of HIV transmission.

Advocates argue that one of the conditions of PrEP is that individuals are tested regularly for STIs (at least every three months). Someone who acquires an STI will therefore be quickly treated, meaning better outcomes at both an individual and population-wide level.

Truvada as PrEP is not available in Australia but it was much discussed at the International AIDS Conference in Melbourne in July of this year where many HIV-experienced Australian doctors supported providing Truvada for people in serodiscordant relationships. (There appeared, however, to be division amongst doctors on the question of whether PrEP should be made available for HIVnegative people engaging in condomless sex with multiple partners.)

There are currently a number of PrEP trials underway across the country. Associate Professor Edwina Wright is chief investigator of the VicPrEP study. She says the findings from the study should help inform decisions about the feasibility of a PrEP service in Victoria. "We are looking at the acceptability of PrEP, adherence to it and whether behaviour change occurs while on it,” said Wright. “A recent study from the Kirby Institute suggested that it would only be cost-effective to give serodiscordant couples PrEP. We are hoping our data will prove that it should be extended to other at-risk people."

The consensus among HIV organisations in Australia seems to be that PrEP is a valuable additional method of protecting against transmission. ACON’s acting CEO Karen Price said: "While condoms remain the best protection against HIV transmission, having other methods of prevention available to gay men is vital in reducing transmission rates."

Of course the Australian conversation has only just begun. But if the American experience is anything to go by, stay tuned for a long and protracted battle to get PrEP approval here.