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The End of Condoms?
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Doctors are quietly giving AIDS drugs to people who like unprotected sex. They say the pills can prevent HIV, and now some activists are scared—that it actually works.
Since the beginning, Dr. Marcus Conant has been at the frontlines of HIV treatment and prevention. In 1981, the San Francisco-based dermatologist was one of the first medical professionals to successfully identify the symptoms and syndromes eventually classified as AIDS, and he remains a pioneer in innovative HIV-prevention strategies to this day.
“There is this cultural reluctance to giving people pills that allow them to do things we don’t want them to do.”
But for the past half-decade, Conant has been doing something with no outside observation that’s considered blasphemy by many AIDS specialists: he’s prescribing powerful HIV meds to people who don’t have HIV.
Adhering to strict dosage guidelines and carefully monitored for potential side-effects, Conant’s clients are early adopters of a controversial drug cocktail called PrEP—pre-exposure prophylaxis medications. The concept is simple: Conant uses the same anti-retrovirals (ARVs) that HIV-positive patients take to manage their disease, and administers them to high-risk HIV-negative people in the hopes that the meds will prevent them from catching the virus.
Or at least, that’s how it’s supposed to work. Still unproven—and possibly illegal—PrEP is upending the AIDS world, as it conflicts with the “Always Use Condoms” mantra that’s been at the center of AIDS-prevention strategies since the beginning. But PrEP advocates don’t mind that. They think of themselves as realists in an era where people just aren’t as scared of AIDS as they used to be. “Many of these patients have simply given up condoms, but are still looking for ways to stay negative,” says Dr. Conant of his PrEP users, who are all gay.
From San Francisco to South Africa, Brazil to Botswana, more than 20,000 people—men and women, gay and straight, singles and couples—are either currently enrolled in or slated to begin PrEP studies across the globe. And results from the first study—a CDC-sponsored trial on 400 gay men nationwide – are scheduled for release early next year. While researchers are reluctant to speculate on the potential outcome, previous studies in monkeys—and anecdotal “street” use—suggest PrEP is likely to provide some measure of protection against HIV. “We’re cautiously optimistic,” confirms Dr. Kenneth Mayer, medical research director at Fenway Health in Boston.
If the PrEP trials bear out, AIDS could join the hallowed club of diseases preventable by pill. But AIDS, caught in a 30-year swirl of sex and morality, has never been just another illness. As the late-‘80s battles over condom use and needle-exchange programs illustrate, HIV-treatment debates have rarely focused solely on bottom-line results.
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DBFan2009
"the end of condoms?" such a misleading headline. condoms were invented long before HIV-AIDs made its deadly appearance. not only useful in preventing pregnancy but also other STDs. pretty obvious, of course, but not to the DB headline writer.
Counterglow
Lovely...so people who engage in the most irresponsible behaviour help breed the next generation of drug-resistant superbug because they're too selfish and reckless to use protection.
What's wrong with this picture?
Mike-Hartley
you
Charlemagne712
actually no, counterglow is exactly right. all it takes is 1 cell to survive the cocktail and we have a brand new epidemic that we dont have treatments for.
Mike-Hartley
Globally, in 2007 somewhere between 30 and 36 million people were living with HIV. There were between 2.2 and 3.2 million new infections. Although on balance rates of new infection appeared to be declining, this is not true everywhere.
The UNAIDS 2008 Report on the global AIDS epidemic states:
'The global HIV epidemic cannot be reversed, and gains in expanding treatment access cannot be sustained, without greater progress in reducing the rate of new HIV infections.'
The post discusses one possible area of progress. Counterglow's own best ends are best served by celebrating this, with caution, rather than moralizing.
At what point do we take action, even with the risk of making things worse? When it gets closer to you perhaps? I would suggest it already is.
DCJeepGuy
Also, the number of people on HIV drugs is still relatively small when compared to other drugs so the increased number of users should help reduce the costs considerably.
bigticket
Mmm you must like to inseminate the ladies in your own highly responsible manner.
DCJeepGuy
So if they came out with a vaccine tomorrow, that would be different how? If people could take a shot to prevent HIV they would and then give up condoms. The risk of other std's is not as life threatening (except for HepC).
If taking PrEP delays/slows the infection rate then it should be used. As advancements in drugs and gene therapy continue treatment should become more effective, safer and easier.
mcmchugh99
As a libertarian, I don't care what consenting adults do sexually. These drugs may be widely available in teh wealthy countries, but not so much in the developing world, where this epidemic has become just another disease that adds to the miseries of the poor--which are even worse in this depression.
Their best hope is that one of these vaccines works at some point in the future.
johnnyapplecd
McMc-- as a regular reader and enjoyer of your comments and the insane reactions they cause, I have to say, you are no libertarian.
I'm pretty sure I've nodded my head in agreement to several of your suggestions that "TBTF" corporations whom are about to collapse on the middle class be completely nationalized, rather than bailed out and allowed to start the whole process all over again with no oversight or penalties. This is completely antithetic to the LIbertarian Party platform, but has an awful lot in common with the Socialist Worker's Party.
That's meant to be a compliment, not an insult.
Unless, of course, those comments were all meant to be sarcastic.
mcmchugh99
No, I am a democratic socialist and have no more faith in "free market capitalism" than I do in Santa Claus.
As far as what consenting adults do in their sex lives, I think that's their own business. To that limited extent, I'm a libertarian.
demike
What the author was describing is far from a vaccine, just something that may or may not be more beneficial than condom use as a prevention of HIV transmission. To describe it as a vaccine is a further misrepresentation of what this treatment is designed to do. There needs to be a comparison of HIV transmission among groups using PrEP, PrEP and condoms, or condoms alone, and these results should dictate social policy asking what the best sexual practices should be. I'm far from educated on political philosophies, but i don't believe it goes against any libertarian ideal to suggest best practices.
mcmchugh99
I meant one of the vaccines being tested right now, like those in Thailand. I know that the article is about these AIDS treatment drugs that are probably being handed out very widely now anyway, bought over the Internet and so on.
The world's poor have very limited access to these, however,
raindogtoo
This is just wrong on so many levels.
So we're going to fund and develop preventative drug therapy for individuals who are too irresponsible to manage their own behavior and choices?
And I couldn't stop laughing (or crying) when you brought up the social justice angle - where the poor "will be left out of PrEP's initial roll-out and stuck with the old-fashioned barrier method." How could any compassionate society allow THAT to happen???
I'm sure the pharma companies are absolutely loving this.
Mike-Hartley
'So we're going to fund and develop preventative drug therapy for individuals who are too irresponsible to manage their own behavior and choices?'
So this is a bit like the pill, a drug someone takes so they can have sex without getting pregnant. They should just not have sex. Dirty irresponsible heterosexuals.
firebat19
I believe you are misunderstanding the comments these people are leaving, Mike. As far as I can tell, nobody in the comment thread has said or implied that there is anything wrong with people having homosexual sex--or heterosexual sex for that matter. There is a substantive difference between the things you are comparing. Let me clarify a little.
From a public policy perspective, the biggest perceived danger associated with heterosexual sex is pregnancy. HIV-AIDS and other STI's are also significant problems that should not be ignored, but the amount of societal damage caused by teen pregnancy and ineffective birth control is really catastrophic for society as a whole, the individuals affected, and the subset of the population engaging in unsafe sex in this manner. This has been a problem forever. In the middle of the 20th century, relatively affordable and effective birth control medicine was developed and made available. This has NOT solved the problem completely, but on the whole, it has been an incredibly powerful tool in fighting unwanted pregnancies in groups of people who are having sex one way or another. There are really no known society-scale negative aspects of the birth control pill--it really is affordable for the majority of interested parties in the developed world, its proper use is fairly straightforward (though not always followed, unfortunately) and it has no known dangerous side-effects.
The problem many people have with this idea is that HIV-AIDS is very different than pregnancy. It is transmissible between people. The longer it remains in circulation in society, the harder it is to control and effectively treat. PrEP has not been proven to be a "magic bullet," and there are a number of major hurdles to its widespread use. First of all, it can be a dangerous drug, and its regimen is significantly more complicated than that of the birth control pill. The difficulty in achieving proper distribution and use in society is therefore far more pronounced. Secondly, there is not conclusive empirical evidence that it really works (as far as I can tell from this article--I'm not an expert on PrEP). Third, unlike the birth control pill, which costs between $10 and $50 a month, this regimen is expected to cost something like $750 a month. That is more than most people pay for rent and food (per person) combined, and is completely unaffordable for a huge segment of the population. Fourth, the concern that widespread use of anti-retroviral drugs will increase the likelihood of the evolution of untreatable forms of HIV or other viruses is legitimate. The difference in cost to society, a community and the individual of advocating PrEP is astronomical in comparison to that of advocating widespread condom use, and in the case of people at high risk for HIV, not using condoms--which are incredibly effective at preventing STI's--is simply irresponsible. The difference in cost to society between the use of condoms and oral contraceptives in combating birth control is simply not comparable.
Again, I do not think that anyone on this site is attacking people as being irresponsible for having unsafe sex because they are homosexual--it has a lot more to do with the fact that having unsafe sex as a homosexual is irresponsible and dangerous to a lot of other people, and this treatment, for the time being, is not a feasible societal alternative.
jbo206
Uh, the article points out that hetero's catch HIV as well and are also part of the group that have condom fatigue. Irresponsible behavior occurs in both the hetero and homo populations.
dreaday19
The point of the irresponsibility, as I would see it, is the danger of a mutating virus, and hence, the possibility of the mutated virus not being treatable because the drugs you took don't work anymore. It's the same reason its irresponsible to be taking anti-virals for a flu that you don't have. Pregnancy isn't contagious or mutating, so that point is moot.
Mike-Hartley
@firebat19
Regards: 'As far as I can tell, nobody in the comment thread has said or implied that there is anything wrong with people having homosexual sex--or heterosexual sex for that matter.' I agree. But the moral issue of whether we should develop useful drugs to prevent the spread of disease, one group of users of which might be considered irresponsible (people with multiple partners) has been. I just seek to reflect that a vaccine (which I agree this is not, but it is progress and learning) is an important development for everyone., like the pill was. Not just for the 'subset of the population engaging in unsafe sex in this manner.'
Regards the pill. It's fantastic, I agree. I'm a big fan. I also agree about the large potential cost to society of unwanted pregnancy.
Regards PrEP. It's part of the picture. We should celebrate this learning with caution. I'm just trying to do that by pointing out that society has set a precedent with the pill to intervene for the greater good rather than moralize.
Regards: 'Again, I do not think that anyone on this site is attacking people as being irresponsible for having unsafe sex because they are homosexual--it has a lot more to do with the fact that having unsafe sex as a homosexual is irresponsible and dangerous to a lot of other people' I agree with you again, this is my point. This just seems to be the same as 'it's alright as long as they don't flaunt it'. Society has moved on from moralizing about the parents of unwanted pregnancy (in part) and should do the same here.
SantaFromTheNorth
I love your line, "So we're going to fund and develop preventative drug therapy for individuals who are too irresponsible to manage their own behavior and choices?"
We already do that when we have obese people who end up with Type II diabetes or a cocktail of heart medications after the triple bypasses, just as one example. What is you real resistance to this method for AIDS prevention that will probably be way more fail proof than condoms ever were?
As a society, we either care for all our people when they make bad choices or, like Sparta, we cast them out into the wilderness to starve and die.
Is that what you want?
Mike-Hartley
@SantaFromTheNorth - thank you.
@ jbo206 - hetero's at risk should get the vaccine too, I agree.
@ dreaday19 - multi drug resistant HIV is a real issue, I agree. We now have multi drug resistant TB. Does that mean we should never have vaccinated against TB? Regards becoming pregnant and becoming HIV positive. I did not intend to compare them as outcomes, but compare the readiness of society to invest in drugs to reduce the unwanted outcomes of unprotected sex. That is, our society is prepared to invest money in developing a drug to enable unprotected sex that does not lead to pregnancy for no other reason than it is desired. Condoms would be a better public health option than the pill (as they reduce the transmission of disease as well as preventing pregnancy) and are far cheaper. We still invested. I think we should invest in an HIV vaccine also (although a cure would be cheaper, we don't have it, so a vaccine is good). It just seems to me people find it easy to come up with a reason why an HIV vaccine is too costly and is undeserved despite its obvious public health value. I think this is rooted in homophobia, because I don't see the same argument applied to preventing unwanted outcomes in heterosexual sex.
onekind
Just responded to this article at http://www.trevorhoppe.com/blog/archives/2009/09/the_end_of_condoms.html
raindogtoo
Curious that you would bring sexual orientation into it. I don't see the relevance.
I also think you're way off comparing birth control (pill or otherwise) with a meds cocktail intended to allow the user the freedom engage in behavior that most sane individuals would consider both personally irresponsible and a public health risk.
Want the freedom to have sex with multiple partners? Fine! I support that. But freedom means accepting responsibility.
Mike-Hartley
What if you just want to have sex with one partner and he is HIV positive. Is desiring sexual intimacy without the use of condoms with this man personally irresponsible and a public health risk? A desire to be close to another human being in way in which most humans enjoy relationships personally irresponsible and a public health risk?What if its a woman who wants to have sex with an HIV positive man. Are her desires personally irresponsible and a public health risk?
Sexual orientation has everything to do with this because homosexual penetrative sex is seen as a choice not an integral part to sex, it's something to be dispensed with in the name of public health, and heterosexual penetrative sex is seen as a right and a duty, Both are two people enjoying a relationship (no matter how many partners anyone has).
The morality of this is irrelevant. Heterosexuals are afforded the opportunity of risk / condom free intimacy though the use of drugs, why not homosexuals or bisexuals for that matter.
I would wager homosexuals have taken far more responsibility (with multiple partners or not) regards HIV transmission than heterosexual men have regards conception.
raindogtoo
"What if you just want to have sex with one partner and he is HIV positive. Is desiring sexual intimacy without the use of condoms with this man personally irresponsible and a public health risk?..."
>> No it is not. That is one scenario where (assuming the meds are actually effective) that their use could make sense. However, I seriously doubt that the majority of subjects in Dr. Conant's research fit into that category. Certainly the article is focusing on a different set of individuals and behaviors.
"...homosexual penetrative sex is seen as a choice not an integral part to sex, it's something to be dispensed with in the name of public health..."
>> I disagree - or at least I don't see it that way. From my perspective, the issue is having unprotected sex with multiple partners. Under most circumstances (not all, I'll grant you) that implies reckless and dangerous behavior - which does create a public health risks that go well beyond HIV.
"Heterosexuals are afforded the opportunity of risk / condom free intimacy though the use of drugs, why not homosexuals or bisexuals for that matter."
>>> Actually homosexuals have the advantage there - intimacy without fear of unwanted pregnancy. That risk is strictly related to heterosexual intimacy.
"I would wager homosexuals have taken far more responsibility (with multiple partners or not) regards HIV transmission than heterosexual men have regards conception."
>>> 100% agree - historically - but the article speaks to how the tide appears to be changing.
dreaday19
You make a good point, although you're being decently defensive. I don't think too many people care whether you're homo or hetero, and yes, it is important to have sexual intimacy, regardless of orientation. It's everyone's right to have that. However, the public health risk would come from a widespread use of this method.
Mike-Hartley
But mainly. Why invest in the pill, an expensive medical treatment to prevent pregnancy when a condom can do it. Why invest in drugs that prevent HIV transmission when a condom can do it? They are exactly the same. Drugs that enable condom free sex without unwanted repercussions.
Mike-Hartley
@ raindogtoo We're not so different! However, regards:
'From my perspective, the issue is having unprotected sex with multiple partners. Under most circumstances (not all, I'll grant you) that implies reckless and dangerous behavior - which does create a public health risks that go well beyond HIV.'
The HIV epidemic will continue if more than one person is infected by an infected person, it will die out if less than one person is infected by another person. So actually, even though people are clearly at a higher risk of contracting HIV from having multiple partners, and that is possibly a 'reckless' choice, the public health interest is still best served by keeping them negative or preventing them infecting someone else.
@ dreaday19 Regards 'However, the public health risk would come from a widespread use of this method.' Can you please explain this? Are you saying that the possibility of multi-drug resistant HIV is a worse public health outcome than reduced numbers of new infections based on a vaccine? I don't get it. What is the public health risk of a vaccine?
dreaday19
I agree that we should be focusing on getting a vaccine. But the method in this article is not stated that it is. It's taking the anti-retrovirals that people take to manage HIV, which is why I paralleled it to taking anti-virals for a flu if you don't have it (different from flu vaccination). The problem with what you're saying, is that a mult-drug resistant HIV strain, could (quite likely) end up being worse and infecting more people in the long run. Preventing infection now is good, but we need to look at long term effects. If a new HIV strain is found, people may not be safe, and even if they are taking this PrEP method, they won't be safe from the new strain. That's all I'm meaning by public health risk. It's something that needs to be looked at, and considered when doing these studies. Other than that, I think finding a vaccine (or cure) would be nothing short of amazing, and great for everyone.
dreaday19
To add, i guess the possibility of multi-drug resistant HIV is more likely in my mind than yours, if the use of the PrEP method becomes common. Just basing that on general knowledge of viruses and just how incredible they are, and what they can do to survive.
Mike-Hartley
@dreaday19 Agreed.
bigticket
Like using condoms, Raindogtoo?
Cashmoney
PREP seems like an inefficient way to stop spread of AIDS. A pill costs more than a condom and we still don't know what/how often the pill is required. Every day or just before sex? Just after sex? Does one incident of unplanned/unprotected sex render PREP useless? Does PREP work for people who have other STDs that condoms prevent? How much does a year of PREP cost (versus condoms)?
I've had it drilled into me since high school that to avoid pregnancy and STDs, I need to use a condom. They cost next to nothing and you only have to use one during sex. PREP may make for better sex but the treatment regimen could be such a hassle that we end of furhter spreading AIDS.
Count me out.
Mike-Hartley
Correct. A cure would be cheaper to implement than a vaccine.
But a targeted vaccine is probably cheaper than paying HIV treatment costs.
robjh1
Wrap the rascal. There are other diseases to be cautioned about. If you choose to go unwrapped then you are damned.
"and we are not saved..."
sophia5
. . . and the side effects,
and long term effects of the drugs are ??????
Mike-Hartley
Being HIV negative.
sosuede
Your author picture is hysterical, Mr. Kaufman.
JacknBeanPlant
lol, I can hardly agree using ARVs as a PrEP treatment since there are many unfavorable side effects to associated to each drug category. I do agree using the drugs as a first line prophylaxis in the event that the person had sex with someone who may be infected with HIV/AIDS. We can decrease the chances of the virus from replicating.
There are roughly more than 20 of these drugs. And if the person who is taking this as a preventative measure does become into contact with the HIV and the virus is able to "over come" the medication, then that whole class of medication is basically thrown out the window. Therefore limiting treatment options for the person (who now is infected) but was trying to be safe. Secondly, there is no easy way to prevent this, if the person who has HIV and his/her virus is immune to certain medication, that would already render some medication useless already. Imagine the HIVless person going around having sex indiscriminately with multiple people who have HIV and whom have different levels of immunity to our current drugs. This would just open the flood-gates of hell and rendering all our current treatment options useless.
Lets not forget about the side effects associated with these drugs, if these are the same drugs I'm giving currently with my patients. There is no way in hell people, presumably young will likely "enjoy" the side effects. For example, patient taking protease inhibitors (PI) typically see rise in sugar levels, rise in fat levels, gastrointestinal problems, and fat maldistribution. I have seen patients who have taken these meds for a long time to start to developing facial deformation and large fat deposits on their back, not to mention the whole line of other problems they cause. Taking these meds is no cake walk you have to be adherent or else you're screwd.
Last and not least, the title of the article is completely faulty. Condoms and here to prevent all sorts of diseases. Not just HIV/AIDS, one has to be careful. Any woman who taking contraceptives knows that the pill does not prevent STIs from being transmitted from one person or another. If you're going to have sex with someone and you really do care about them (or don't), just wrap it up. And be one less patient I have to care for...
evae1960
Holy Crap!
As someone with a microbiology background and an understanding of the way microbes behave, including the deadly HIV virus, I can tell you that exposing this pathogen to drugs that will absolutely cause it to adapt and mutate is highly irresponsible! Look at the stats. Even this new HIV vaccine they're touting only lowers transmission rates arguably by about 30%!
I don't care who loves whom and how! But, let's not create a new superbug that NO drug will slow down.
wingsabre
What's cheaper, taking a slew of costly pills everyday, to prevent HIV, or wearing a condom? Although this method may assure that HIV will be preventable with a drug, it's not going to be the best idea out there.
Additionally, HIV could potentially acquire immunity to the drugs, and it could mean that there won't be a viable treatment in the future. We'll end up back where we were in the 80s only with much more infected and no effective treatment.
finderj
HIV isn't the only STD.
Condoms do help prevent other diseases.
Let's be careful that we don't take a stance that we later regret.
masalamama
So, should we all start taking Tamiflu too prevent swine flu and others strains not covered in the vaccine? This is a representation of what is inherently wrong with healthcare. We have these healing methods that are costly that treat those who are careless and wreckless. Many diseases are preventable, HIV, STDs, Diabetes, Obesity. The cost of all of this is killing us!
Thank you.
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