Truvada: the political pill

Perhaps it is not good form for one bioethics blog to refer to a discussion taking place on another bioethics blog, but this one is hard to resist. Truvada is an antiretroviral drug originally designed for treatment of HIV infection. But a few years ago, studies showed that use of the drug (as 'pre-exposure prophylaxis or PrEP) could help reduce the risk of getting HIV infected among serodiscordant couples, heterosexual men and women, injection drug users, and transgender women and men who have sex with men. The success -- even if it is only partial reduction of risk dependent on appropriate use -- prompted the approval of Truvada for HIV prevention by the FDA and swift action by influential US and international health bodies, such as the World Health Organisation and the US Centers for Disease Control and Prevention, who have released interim guidance on PrEP use.

So what is going on at the Hastings Forum about this? A provocative piece by Richard Weinmeyer entitled "Truvada: No Substitute for Responsible Sex" expresses deep concerns about the use of Truvada by members of the gay community: a 'prevention pill' will lead to reduction of condom use, further spread of HIV, and an erosion of sexual responsibility among gay men that was already happening due to the discovery of effective treatment and the transformation of HIV (in some settings, at least) into a more or less manageable chronic condition. Why, the author opines, can't gay men just use condoms? The choice for Truvada is (he goes on) a choice for personal pleasure above concern for other persons, and should not be condoned. This is technology in service of irresponsibility. And if gay men are not using condoms consistently (he goes on), then they are not likely to use Truvada consistently either. The argument sounds a bit like: you can't give gay men good things.

It is not clear why he singles out gay men (not the only population Truvada might benefit) or why a tool to help in the struggle against HIV/AIDS is trashed before it even gets out the box. That's the thing: Truvada has been approved for use as HIV prevention but has hardly been flying off pharmacy shelves. The allegedly reckless gay community looking for the 'new condom in pill form' haven't showed up. The reasons behind the lukewarm embrace are multiple, including cost issues, lack of an advocacy base and the suspicion that PrEP is just a way of benefiting pharmaceutical companies. In any case, it is worth going over to visit the Hastings Forum and watching the sparks fly.

Human rights abuse in the name of public health: HIV, ethics and Egypt

In the industrialized nations of the north, it is easy to take for granted the progress made in the control of the HIV virus, and some of the hard-fought, positive changes in the social, ethical and legal treatment of people living with HIV/AIDS. In the United States, regimes of increasingly effective drugs have been developed to control the virus and transform HIV/AIDS from a death sentence into a chronic disease; legal protections specific to persons with HIV/AIDS have been bolstered; social stigma, while by no means absent, has had some of its sharper corners blunted by therapeutic advances and improved public understanding of the modes of HIV transmission.

The fact that this is not the case globally was driven home by a recent report by Human Rights Watch. In Egypt, an HIV positive man -- or even a man suspected of being HIV positive -- is apparently in a far worse situation than their Canadian, American or Western European counterparts. Rather than being able to call on their government for protection, Egyptian authorities strictly enforce a national law against the 'habitual practice of debauchery', i.e. consensual sex between men. Or rather: they go beyond enforcement and towards state-sponsored sadism when it comes to suspected HIV positive gay men, chaining them to hospital beds and eventually jailing them because they are alleged to constitute a threat to public health, testing them for HIV without consent, and subjecting them to abusive and intrusive physical examinations.

Aggressive state action against homosexuals/HIV positive persons in Egypt is a fairly recent phenomenon, and requires an explanation. Hossam Bahgat ventured that the crackdown on gay men is motivated by a desire to (a) distract the public from the country's economic woes and (b) profile the government as a defender of 'Islamic values' (in order to counteract the growing Islamic opposition in the country) rather than a question of public health. There must have been something in those explanations, since Mr. Bahgat was fired from his position at the Egyptian Organization for Human Rights two days after he published them.