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.

HIV drugs plus gender inequality equals non-adherence

Initiatives to increase access to essential medicines in developing countries is, of course, a good thing. It is the building of a lifeline. However, in settings challenged by the legacy of colonialism, hampered by unfair trade policies, and marked by poverty and oppression, it is no small feat to get the right drugs to patients and increase the number of patients served. It is a continuous struggle against the obstacles posed by transport and logistics, bureaucratic administrations, weak health care infrastructure, political inertia and the machinations of global pharmaceutical companies. And it is well-known that once the patients finally get the drugs, the struggle is not at all over. There are still problems of 'adherence', which at first sight may look like mere psychological unwillingness or carelessness in regard to compliance with a drug regime. On closer inspection, 'adherence problems' are really problems in integrating the taking of medication within the life-world of the patient. For one or another reason, it does not fit.

I recently saw a striking news item reminding me of the social complexity that stands behind 'non-adherence.' Apparently a significant number of men in Uganda, living with HIV but not open about their status, are taking medications from their HIV-positive female partners. When antiretroviral treatment was first being rolled out in Africa, I recall anecdotal reports of patients sharing their medicines with those without access to treatment. There the motive behind sharing was understandable and admirable -- a matter of human solidarity -- though the practice was dangerous as it meant improper dosing for all involved. The Ugandan case is different: the men probably would have access to treatment if they declared their status and appeared at clinics (apparently this is not just a Ugandan phenomenon). And this is stealing, not sharing, apparently facilitated in some cases by gender-based violence. So this is a new way of being 'non-compliant': having an aggressive partner unable to come to terms with his own HIV diagnosis.