Acworth, Weinstein Square Off on PrEP on NY Times Website

CYBERSPACE—As if they needed anything else to fight about—besides AB 1576, that is—Kink.com owner Peter Acworth and AIDS Healthcare Foundation (AHF) president Michael Weinstein squared off in one of The New York Times' regular features, "Room for Debate"—and this time, the topic was using pre-exposure prophylaxis (PrEP)—specifically, Truvada—to guard against HIV infection. Weinstein, of course, has long opposed the development, approval and recommended use of PrEP, having once referred to Truvada as a "party drug." However, studies have found that, if taken daily, is 90 percent or better at preventing users exposed to the HIV virus from actually becoming ill with the disease—but that's made little difference to Weinstein's opposition, and he reaffirmed that position here. "PrEP has failed to protect the majority of men in every clinical trial (study)," Weinstein wrote, omitting the fact that many of the test subjects failed to take the medication as prescribed. "Relying on negative men to take this medication every day just doesn't happen most of the time. If you have multiple partners over a long period of time and you are not using condoms, there is a very high likelihood that you will turn H.I.V. positive or contract other S.T.D.'s. Sorry to deliver the bad news." Weinstein puts down the drug's efficacy by noting that "this generation didn't live through the holocaust of the '80s and '90s" when gay men were dying by the thousands and no treatment for the disease existed, and he further claims that, "We know that young people think they are invincible and that self-esteem plays a huge role in sexual risk-taking. It is not a surprise that gay men, as most men, prefer intercourse without condoms."—so of course, the answer is to abandon a drug which has shown to work in many cases, and just go with condom use in every sexual encounter. Acworth, on the other hand, sees that from the point of view of someone involved in the adult industry, who sees people having unprotected sex every day, and is aware of the effectiveness of the industry's testing procedures, sees Truvada as a valuable tool in preventing infections among sex workers. "Due to the efficacy of these [testing] protocols, the adult industry has not had a single documented case of on-set H.I.V. transmission since 2004," Acworth wrote. "During that same ten year span, however, a handful of performers have tested positive at their biweekly tests. Through viral genealogy, doctors were able to trace each of these transmission to their personal lives, where the people they encounter may not be tested. But just because it didn’t happen on set, doesn’t mean it shouldn’t concern us. After all, these are our co-workers, our friends, our family. For those of us who truly care about performers, Truvada offers a way to protect them both on set and off." Acworth's "better safer than sorry" philosophy is one he'd extend to everyone, but particularly to adult performers like Cameron Bay and Rod Daily, who apparently had engaged in off-set sexual activity that resulted in one of them becoming HIV-infected. "Had these performers [Bay, Daily and others infected in 2013] been taking Truvada, on the other hand, they still could be H.I.V. negative," Acworth cautioned. "We owe it to performers and other sex workers to move beyond old models of prevention and educate them about all the safeguards at their disposal—including PrEP—and let them decide for themselves whether they are taking risks that might be mitigated by use of PrEP. Morality and politics shouldn’t cloud prevention, on-set or off." At least two other debaters agreed with Acworth, though with some reservations. "What’s not to like about Truvada?" asked Renato Barucco,  head of the Transgender Family Program at Community Healthcare Network in New York City. "Why are we debating whether PrEP is a sound strategy? Public health advocates who aren't enthusiastic about PrEP worry that people may not take the drug consistently, facilitating new infections and the development of strains of H.I.V. resistant to Truvada. Additionally, PrEP, which is highly but not completely effective, could discourage condom use by giving people a misleading sense of immunity to H.I.V." Barucco goes on to note that because of Truvada's high price, it's "not a realistic option for many people at risk, including teenagers and young adults, who account for 26 percent of all new H.I.V. infections in the United States" and "are often uninsurable and may struggle to pay for medical visits, or they might live in areas with deficient access to H.I.V. medications." But even with those caveats, Barucco answers his own question of whether PrEP is a good idea by noting, "PrEP works. Any prevention tool that limits the spread of H.I.V. in communities at risk has intrinsic value. What could be problematic is to let the excitement surrounding PrEP obscure our commitment to other prevention strategies. PrEP in isolation is tepid news. PrEP in addition to the growing range of prevention tools is a treasure... I welcome PrEP." Kenneth Mayer, a professor at Harvard Medical School and a director of HIV prevention research, feels similarly. "The use of prophylactic medicine to prevent the acquisition of infection is not a new concept," Dr. Mayer began. "Many travelers have taken antimalarials when traveling to endemic regions. In recent years, 4 of 6 studies that enrolled thousands of participants demonstrated that the prophylactic use of antiretroviral medications (tenofovir and emtricitabine) significantly reduced the risk of acquiring H.I.V. among at-risk participants, which not only includes men who have sex with men but transgender women, heterosexuals and injecting drug users." And while Mayer worries that users of PrEP "might increase their number of condomless sex acts if they think they are protected by the pill," he nonetheless concluded that, "with about 50,000 new H.I.V. infections in the U.S. each year, and almost 2 million new infections globally, there is an urgent need for the deployment of new prevention modalities. PrEP is a medication that must be prescribed and monitored by informed providers. It can cause some side effects and lab abnormalities, but is generally well-tolerated." The fifth "debater" was long-time gay activist Larry Kaplan, who shared others' concern about PrEP's—and particularly Truvada's—possible side effects from long term use, stating, "Truvada could be useful for health care professionals who are exposed to H.I.V., as a prophylactic day-after pill," and warned, "There is already a lot of complacency among gay men that makes the lucky uninfected neglect or reject condom use. So we don't know the full story well enough to be raving so uncritically and warning so little." Sadly, The Times didn't elect to solicit more points of view, but at least most of those it did choose think PrEP and Truvada are useful tools when taken as directed, especially if used with condoms. And once again, Michael Weinstein finds himself the odd man out when it comes to fighting the disease his organization was set up to treat... and prevent.