Truvada as preventative for HIV: Careless use can only make things worse
The health authorities are discussing the controversial drug, but doctors fret about unintended consequences
There is a pill that can prevent infection with HIV, the virus that causes AIDS. The United States has become the first country in the world to allow the use of Truvada as a prophylactic agent: In fact, the Centers for Disease Control and Prevention caused an uproar last week after recommending that hundreds of thousands of Americans at risk take it daily.
Though Truvada is widely used around the world in the “drugs cocktail” for AIDS, nowhere else is it used prophylactically. Israeli authorities are studying prophylactic use of the drug, though for now, it is not locally available as a preventative.
Even if it gains approval in Israel, some doctors fear unintended consequences, such as neglect of safe-sex practices.
Meanwhile, over in America the FDA had already approved Truvada in 2012 as pre-exposure prophylaxis (PrEP) for HIV, but the new guidelines issued this month could lead to widespread use.
Even if it is approved for preventative use, that doesn’t mean one can leap into unprotected sex without a second thought.
Truvada is no replacement for a condom, cautions Dr. Michal Chowers, chairwoman of the Israeli medical society of aids, and director of the Infectious Diseases Unit at Meir Hospital in Kfar Sava. “First of all, a condom is more effective against infection with HIV, and it also protects against other sexually-transmitted diseases that Truvada does not protect against,” Chowers says. “Also, the drug would be administered to a completely healthy person who’d have to take it every day, remain under medical supervision and have blood tests every three months because of possible side-effects, such as kidney problems.”
It also costs a fortune, Chowers adds, and “It’s only effective if taken properly, every single day. In studies that were conducted, roughly 40 percent of the subjects didn’t take the drug every day, so they were not fully protected.”
Perfectly healthy people taking strong medicine
Truvada works by inhibiting the key enzyme, reverse transcriptase, that the HIV virus needs to infect host cells. It therefore effectively blocks infection.
When taken daily, Truvada provided protection between 96% and more than 99% against HIV, according to iPrEx, a clinical trial conducted among men who have sex with men and sponsored by the U.S. National Institutes of Health.
The new American guidelines list a lot of groups for whom Truvada is recommended: anyone in a relationship in which one partner is a carrier or ill; heterosexuals who have frequent casual sex; men who have sex with other men without protection or who have had sexually-transmitted diseases in the past; sex-industry workers and people who take drugs by injection.
True, the incidence of HIV carriers in the U.S. is much higher than in Israel, where the number of carriers among heterosexuals is particularly small.
“I feel the recommendations are too sweeping. That’s 70 percent of my patients who come to the gay center,” says Dr. Gal Wagner Kolasko, a general practitioner at the Gan Meir LGBT Center in Tel Aviv. “You have to meet with a person to understand his sexual activity well. But in any case, we have to remember that the number of gay people with HIV is increasing. Every week, three more Israeli gay men discover that they’re carriers, and it’s assumed that about 10 percent of gay men in Tel Aviv are carriers.”
Although it’s not well-known in Israel, some are aware of Truvada’s prophylactic quality and want to take the drug. The problem is that doctors aren’t allowed to prescribe it for that use, and it is not included in the subsidized health basket as pre-exposure prophylaxis – so even if they could buy it, taking it costs about NIS 3,000 per month. That’s a hefty bill for a preventative. This means those people have to get it by other means, which can lead to activity that’s not only illicit but dangerous.
Truvada as a prophylactic is a key topic at a discussion hosted by Kolasko, with Dr. Ruth Gofen, at the "Talk Health with Pride" conference Thursday at the LGBT Community Center in Tel Aviv.
Desperately seeking Truvada
There are accounts of Israelis who go to hospital, claim to have had unprotected sex and ask for the post-exposure prophylaxis (PeP) cocktail, which includes Truvada. They keep the Truvada and use it later on. Others travel to Africa and get a cheap generic version of the drug. One risk is that irregular use of Truvada will spur the development of resistant strains, similarly to bacteria and antibiotics – witness the spread of “superbugs.”
The same is true if one takes Truvada alone while already infected with the virus. Among HIV carriers, the drug has to work in tandem with other drugs in a cocktail that together “attack” the virus from different directions. If taken alone, again, the virus has the potential to develop resistance.
Israeli doctors attest to meeting people who take Truvada the day before they go out to have fun and the day after, evidently not realizing that the drug is not effective when taken that way. “For the drug to have an effective level in the blood, it has to be taken for a week at least. If they want to have sexual relations at least once a week, they have to take it every single day,” Dr. Chowers says.
The attitude toward Truvada is akin to the time when the birth-control pill was invented, says Dr. Wagner Kolasko, who is also a medical consultant for the Israel AIDS Task Force.
“Similarly, they take healthy people and tell them: Take this pill every day. It has side effects, it’s not clear that it will be 100-percent effective, and it may make people stop using other birth-control methods,” he elaborates.
Popular among porn actors
Truvada has become particularly popular with porn actors, especially among those who make “bareback” films, in which the actors do not use condoms.
The Jewish porn star and producer Michael Lucas, who is known for his political support of Israel (he’s made several porn films here with the participation of Israelis), announced that he takes Truvada regularly. These days, his company is filming more scenes of anal sexual relations without condoms, including scenes in which Lucas himself appears.
“I think that if you’re having sex without a condom anyway, whether it’s in front of the camera or at home, it’s better to take the drug,” says Dr. Wagner Kolasko. “Of course, it’s preferable to have sex with a condom in any case. The risk doesn’t justify the entertainment.”
Dr. Chowers says that for some, the benefit outweighs the potential for damage. “We advocate safe sex and condoms first of all, but that exists only in an ideal world. Some people do as they please. We treat people who have unprotected sex and then come to get treatment after exposure, and two months later they have unprotected sex again and come for treatment once again. It might be more logical to put these people on pre-exposure prophylaxis, but that is not the solution for everybody. It’s appropriate for a group of people about whom you say that the other solutions will fail.”
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