May 26, 2014

Medicine on the verge of drastically reducing and preventing HIV for a second sexual revolution

Federal health officials recommended two weeks ago that hundreds of thousands of Americans at risk for AIDS take a daily pill that has been shown to prevent infection with the virus that causes it.

If broadly followed, the advice could transform AIDS prevention in the United States — from reliance on condoms, which are effective but unpopular with many men, to a regimen that relies on an antiretroviral drug.

It would mean a 50-fold increase in the number of prescriptions for the drug, Truvada — to 500,000 a year from fewer than 10,000. The drug costs $13,000 a year, and most insurers already cover it.

Predictably, a backlash has arisen. Some men who use it instead of condoms are called “Truvada whores.” Some complain of being “slut-shamed” by their own doctors, who are reluctant to write prescriptions. Opponents said that syphilis and gonorrhea rates, already high among gay men, would worsen.

For now, Truvada has no Andromeda or Margaret Sanger. The C.D.C. recommendations were released quietly, with no news conference. And Gilead Sciences, its maker, doesn’t advertise it for PrEP.

The new drugs permit even grander ambitions. By treating enough inhabitants, the whole “viral load” of a city can be lowered. That protects everyone — just as cities used to slow down smallpox outbreaks by rapidly vaccinating thousands of inhabitants.

In Vancouver, British Columbia, 16 years of an aggressive test-and-treat policy paid for by local government lowered new H.I.V. diagnoses by 66 percent. In San Francisco, the city’s viral load has dropped even though test-and-treat was adopted by public clinics only four years ago.

Even Rwanda has seen the effect. Thanks to donors, 87 percent of Rwandans needing triple therapy are on it. New infections have dropped 60 percent.

Admittedly, these are isolated examples. There are still 50,000 new infections a year in the United States, and 2.3 million worldwide.

Widespread use of the drugs could fight that — but two imposing obstacles loom.

The first is psychological. Doctors and policy makers need to admit that 30 years of the ABC mantra — abstain, be faithful, use condoms — has failed. Men generally hate condoms, their lovers usually give in, almost no one abstains, precious few stay faithful.

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