Call it the great debate of AIDS 2012.
During a Monday, July 23, workshop event, speakers and attendees illustrated both the support and suspicion of using antiretrovirals as a method of preventing HIV-negative people from becoming positive. Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS, argued in favor of "treatment as prevention" through antiretrovirals, while Kenneth Mayer, medical research director and co-chair of Boston's Fenway Institute, countered that more research needs to be done before the medical community endorses pre-exposure prophylaxis (PrEP). Audience members – on both sides of the issue – also spoke passionately.
The debate comes one week after the FDA announced it had approved the antiretroviral drug Truvada for daily use as a PrEP component, in combination with safer-sex practices, to reduce the risk of HIV infection among adults considered at high risk of acquiring the virus, such as men who have sex with men (MSM), serodiscordant couples where one partner is positive and one is negative, and sex workers.
Montaner cited statistics from a study done in British Columbia that showed as access to antiretrovirals was expanded, new HIV diagnoses decreased. He said that the success that HIV/AIDS medical professionals have had in treating HIV-positive pregnant mothers with antiretorvirals to ensure their children are born without the virus shows the promise of using such treatments for uninfected adults.
“We need to do this without any further delay,” Montaner insisted.
Mayer, however, spoke of unknown effects of such therapies in healthy individuals with normal CD4, or T-cell, counts. He mentioned the possibility of resistance to the medications over time among people with normal CD4 counts as a possible side effect, particualry in cases where adherence is lax.
Mayer and Sean Strub, founder and advisory editor of POZ magazine, also warned that while linking people with care is an admirable goal, public health officials may use antiretrovirals as a crutch of sorts, recommending it for all people regardless of the nature of their serostatus, instead of basing their recommendations on science. Strub, as well as some audience members, also raised questions about the ethical issues that accompany scientific advances such as antiretrovirals.
Other considerations discussed and debated were the cost of such medications, the prioritization of patients who would be able to access those treatments, and the toxicity of the drugs. In addition, medications used as prevention could only be completely effective if they were used along with other prevention methods, such as using condoms during sex. To ensure that resistance to the drugs would not develop, health care providers would also need to stress the importance of interventions, such as regular HIV testing, and would have to be appropriately trained to do risk assessment or to provide the appropriate counseling to patients seeeking treatment.