New York • It’s the Truvada conundrum: A drug hailed as a lifesaver for many people infected by HIV is at the heart of a rancorous debate among gay men, AIDS activists and health professionals over its potential for protecting uninfected men who engage in gay sex without using condoms.
Many doctors and activists see immense promise for such preventive use of Truvada, and are campaigning hard to raise awareness of it as a crucial step toward reducing new HIV infections, which now total about 50,000 a year in the U.S. Recent efforts range from think-tank forums and informational websites to a festive event at a New York City bar featuring popular drag queens.
Yet others — despite mounting evidence of Truvada’s effectiveness — say such efforts are reckless, tempting some condom users to abandon that layer of protection and exposing them to an array of other sexually transmitted infections aside from HIV.
"If something comes along that’s better than condoms, I’m all for it, but Truvada is not that," said Michael Weinstein, president of the AIDS Healthcare Foundation. "Let’s be honest: It’s a party drug."
Even as gay-rights organizations celebrate collective progress in the fight to legalize same-sex marriage, the less-publicized Truvada debate has fueled bitter divisions within the gay community. Some who use the drug say they’ve felt shamed by some who don’t, and there’s now a lively backlash by users and their allies, including promotion of a "Truvada Whore" T-shirt.
"The discussion can torch emotions like a flame-thrower on a fuel depot," wrote Steve Ramos of the Dallas Voice as the gay-oriented publication reported on the debate in March.
Truvada, produced by California-based Gilead Sciences, has been around for a decade, serving as one of the key drugs used in combination with others as the basic treatment for people who have the AIDS-causing virus HIV. However, the drug took on a more contentious aspect in 2012 when the Food and Drug Administration approved it for pre-exposure prophylaxis, or PrEP — in other words, for use to prevent people from getting sexually transmitted HIV in the first place.
Since then, critics have warned that many gay men won’t heed Truvada’s once-a-day regimen and complained of its high cost — roughly $13,000 a year. Truvada’s proponents say most insurance plans — including Medicaid programs — now cover prescriptions for it, and they cite studies showing that the blue pill, if taken diligently, can reduce the risk of getting HIV by more than 90 percent.
Dr. Demetre Daskalakis, medical director of the ambulatory HIV program at New York’s Mount Sinai Hospital, served on the FDA panel that recommended approving Truvada for preventive purposes and is among many doctors who hope that doubts about it fade.
"For folks who are having a significant amount of unprotected sex, it’s a slam dunk — not only giving them protective medicine, but engaging them in testing, a whole package of regular health care," he said.
Yet Daskalakis says that out of his large clientele, only about 25 men are taking Truvada for prevention.
"There’s some interesting social pushback," he said. "I’ve spoken to some of my patients who’d totally be candidates but are hesitant to do it. They don’t want to be labeled as people on the drug because there’s a social stigma."
Daskalakis is dismayed by groups like the Los Angeles-based AIDS Healthcare Foundation — one of the country’s leading HIV/AIDS service providers — which suggest that prescribing Truvada for prevention means condoning condomless sex.
"I find some of that opposition irresponsible," Daskalakis said. "If some men don’t want to use condoms, they won’t. You have to deal with it by acknowledging that sometimes unprotected sex happens, and you can still prevent HIV infections."
To date, preventive use of Truvada appears to be limited, due partly to misgivings among some gay men and partly to lack of awareness.
According to Gilead, 1,774 people starting using Truvada for prevention between January 2011 and March 2013 — nearly half of them women. The company said more recent figures aren’t available, but health officials in several cities said they see no signs of a major surge in usage.
"Out of our thousands of patients, we have about 20 on PrEP," said Dr. Robert Winn, medical director at Philadelphia’s Mazzoni Center, which serves many gay clients.
"Many ask about it, few take it," Winn said. "The number one reason for that gap is the commitment of having to take it every day."
Weinstein, the AIDS Healthcare Foundation leader, takes heart from the low usage figures, saying they bear out his reservations about Truvada. He says he’s undeterred by criticism of his insistence that condomless sex — even in the Truvada era — should be discouraged among gay men with multiple partners.
"There’s an element in the gay community that espouses ‘anything goes,’ that is for sexual freedom and not giving an inch," he said. "But demonizing me or AHF isn’t going to shut us up."
Another Truvada skeptic is Richard Weinmeyer, a research associate with the American Medical Association’s Ethics Group. In an article in February in Bioethics Forum, Weinmeyer — expressing his personal views — argued that preventive use of Truvada could encourage sexual irresponsibility.Next Page >
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