I attended at cozy talk about HIV
prevention and treatment earlier this year at the suggestion of my mentor. The expert
presiding over the talk was a local expert in HIV management, thus it was an
opportunity I did not care to miss. During the discussion he started to
reference recent study data suggesting the use of antiretroviral (ARVs)
medications as prophylactic HIV treatment for "at risk" patient populations.
This spurred quite a debate among the attendees, many of whom argued that with
the problems associated with ARV resistance, prophylactic use of the drug
seemed like an undeveloped idea. The dinner promptly concluded; my mentor and I
discussed aspects of the talk the following day at work and I didn't think about
it again until yesterday.
Why yesterday, you ask? Well,
yesterday, as I was flipping through the idiot box, I spotted a tickertape news
scroll headline that noted an FDA panel was considering approving Truvada for
use of HIV prevention. (Truvada is an ARV composed of emtricitabine and tenofovir,
both nucleoside/nucleotide analogues.) So what in January had seemed like a
mere hypothetical conjecture amongst epidemiologists is poised to become an
active form of prevention. The world moves pretty fast.
dinner conversation I chose to be agnostic. As a newbie I didn't feel I had
much in the way of knowledge or experience to add to the conversation. Five
months later, I hardly feel like an expert; however, I have had five more
months of experience with HIV management and thus believe that the use of ARV
as prophylaxis amongst at-risk populations is unwise. ARVs are expensive and
they have to be taken every day without exception. There are no drug holidays
for ARVs: to do so is to risk courting drug resistance. Additionally, these are
not totally benign medications. ARVs, tenofovir in particular, can precipitate nephrotoxicity
and lead to decreased bone density with long term use. So in addition to the
actual cost of the drug, there is the built in cost of managing a patient on
Truvada (e.g. blood work, clinician visits).
Like so many things in health care,
eligibility for Truvada as prophylaxis will come down to cost. I don't agree
that attempting to halt the spread of a deadly virus should simultaneously
engender economic inequity. As a clinician I advocate for increased condom use
and improved sex education. Not only do they work, they are cost effective.