Quelling Common Concerns About The HIV Prevention Drug PrEP
PrEP is a powerful new tool in the worldwide public health campaign to prevent new HIV infections. Years of rigorous clinical trials have proven that the single pill daily regimen can prevent HIV negative individuals from contracting HIV from positive individuals. Many patients and providers understandably have concerns about the unintended consequences of administering antiretroviral drugs to healthy people.
One of the biggest worries is that widespread availability of PrEP will give people an excuse to forgo condoms. The truth is that people already have plenty of excuses to not use condoms, which is a big part of the reason we have so many infections today. People have many strategies other than condom use to prevent the spread of HIV such limiting their number of sexual partners, only having sex with HIV positive individuals who have an undetectable viral load and serosorting, which means having sex with people with the same HIV status as themselves. These methods have varying degrees of effectiveness, and many people employ more than one strategy, which healthcare advocates are now calling "the prevention tool kit." Using any or all of these tactics helps prevent the spread of HIV and demonstrates taking responsibility for one's sexual health.
Condoms can be highly effective at preventing the transmission of HIV; however, they are not infallible. They can break or slip off if not worn properly, and people report inconsistent condom use for a variety of reasons such as:
- Lack of access to condoms when they need them
- Having sex while impaired by drugs or alcohol
- Lack of sexual pleasure and difficulty maintaining an erection
- Feeling that condoms are a barrier to emotional intimacy
- Having partners that refuse to use condoms and threaten emotional, financial or physical violence when condoms are insisted upon
Decades of research and common sense has shown that millions of men, women and transgender people of all sexual orientations do not use condoms during vaginal or anal sex. Many HIV positive individuals are unaware that they have the virus, so assuming that everyone knows their status is a faulty assumption, and shaming people who do not use condoms isn't an effective public health strategy.
Think about it in the context of tobacco use: Everyone now knows that cigarette use increases one's risk for cancer and other maladies, yet millions of people continue to smoke. Everyone also knows that overeating and lack of exercise can lead to health problems, yet obesity remains a public health concern. Many people now understand how HIV is transmitted, but that doesn't stop them from taking risks. PrEP gives people one more option to lower their risk of contracting HIV.
During the initial outbreak of HIV in the early 1980's, no treatments existed, so an HIV diagnosis was almost always perceived as a terminal illness. Condoms were the only way sexually active people could protect themselves, and a lot of them were fortunately able to change their behaviors leading to a drop in new infections during the late 1980's and early 1990's. Since highly-active antiretroviral therapy has transformed HIV into a manageable chronic illness rather than a death sentence, infection rates have been back on the rise, especially in minority communities such as gay, bisexual, black and Latino populations.
Individual choices are not the sole factor that determines someone's risk for HIV. Like many health problems, HIV is more concentrated in socioeconomically disadvantaged groups because they lack access to healthcare and quality sex education. Since PrEP has proven effective in clinical trials, future research will focus on how PrEP can help reduce new infections in specific communities.
PrEP skeptics may wonder why a healthy person would choose to take a pill everyday and if we can really trust them to be adherent. Fortunately, we already have a successful example of such a phenomenon: Millions of women across the globe take a pill to prevent pregnancy each day. Some women have trouble adhering to birth control as some patients will undoubtedly struggle with adherence to PrEP, but oral contraceptives have been highly effective at reducing unplanned pregnancies in the past half-century. Many women choose to use condoms in addition to birth control, and many PrEP patients will likely still use condoms for extra protection as well. Like birth control, PrEP will give people peace of mind and agency over their own bodies and lives.
Perhaps the biggest concern raised by PrEP critics is an ethical one: Given that millions of people living with HIV lack access to antiretrovirals, should we be giving them to healthy people? This is a very legitimate question. Issues surrounding affordability and access are complex and being addressed by governments, nonprofits and pharmaceutical companies. In the meantime, however, PrEP has been scientifically proven to reduce new HIV infections, so it would be unethical to withhold it from the general public. Ending the worldwide AIDS pandemic requires a two-fold strategy of making sure all HIV positive people have access to medications and uninfected individuals stay uninfected. PrEP will hopefully propel us one step closer to an AIDS-free generation.