When asked about the risks of Truvada, Dave Cullen answered in three quick parts: healthcare costs (discussed by readers here), side effects, and people not taking the drug consistently:
A New Yorker piece backs up Cullen on the side effects:
Taking Truvada to prevent H.I.V. comes with very few risks. In the N.I.H. study, one in two hundred people had to temporarily go off the pill owing to kidney issues, but even those people were able to resume treatment after a couple of weeks. While bone-density loss occasionally occurs in Truvada takers who are already infected with the virus, no significant bone issues have emerged in the PrEP studies. And though about one in ten PrEP takers suffer from nausea at the onset of treatment, it usually dissipates after a couple of weeks. According to the U.N. panel’s Karim, Truvada’s side-effects profile is “terrific,” and Grant said that common daily medications like aspirin and birth control, as well as drugs to control blood pressure and cholesterol, are all arguably more toxic than Truvada.
A reader is still worried about the indirect risks of PrEP:
I’m sympathetic to your position; I will probably take Truvada when I’m at Bear Pride in Chicago. I plan on using condoms anyway, but … you know. Alcohol and all that. Sometimes you don’t pay attention.
But for the record, I do think the points that those concerned about Truvada raise regarding substituting it for a general sexual health strategy are reasonable in some ways. Case-in-point: gonorrhea. I can tell you right now, I am much, much more afraid of drug-resistant gonorrhea than I am of HIV.
One criticism I’ve read of Truvada is that if lots of gay men start taking it, but even a small subset of them do not take it as directed, i.e. once a day, that it could lead to different resistant strains and a strengthening of the virus? Is that at all true?
[Jim Pickett, the director of advocacy for the AIDS Foundation of Chicago] told me he believes drug resistance is “something to be watchful for,” but not a huge concern of his for a few reasons.
One is that resistance is common in the world of HIV medications. He said he’s HIV positive himself, and has been on various meds since 1997, building up resistance to “a whole bunch of drugs over the years.” And because maintaining a Truvada prescription requires a comprehensive HIV test every three months, Pickett suggested that there would be opportunity to keep a mutant strain of the virus contained:
And if you were going in for your refill and it was found out that you were actually positive, they could immediately determine what kind of strain of HIV you have. If it has any kind of genetic alterations due to it being exposed to a certain drug, suboptimal levels of drug, that could be determined. It could also be determined that you don’t have any drug in your system. And if you don’t have drug in your system, you can’t be resistant.
You also can’t be resistant if you don’t become HIV positive. People get confused about that a little bit, like the drug itself can create resistance. Well, the drug has to be at suboptimal levels and come into contact with HIV. If you don’t come into contact with HIV, no resistance. If you come into contact with HIV and you don’t have any drug in your system, no resistance. It’s just that suboptimal part. But it’s a harder thing to happen than I think people think about.
Another reader notes an obvious way to lower such risks:
I wish the discussion would remember that many gay guys – I think I once heard Dan Savage say as many as 30 percent – spend their entire lives without having anal sex, and that a lot are also in situations where they’re already at extremely low risk of contracting HIV, such as men who aren’t as active sexually or prefer practices that don’t involve intercourse. While the current safe sex rhetoric is obsessed around condoms, it is so because it is also obsessed around equating male homosexuality with anal intercourse, and sexual expression shouldn’t just be about one act.
Another risk-averse reader wrings his hands:
I’m a 38-year-old gay man, young enough that none of my friends died of AIDS but old enough that I have spent virtually my entire conscious life worrying that I would die from it. I’m a rarity: a fully condom-compliant gay man. I’ve never had difficulty using them and have never had sex without them, except with my husband.
Plus, I’ve always tried to avoid having sex with guys who don’t use condoms regularly for casual sex. Avoiding barebackers is a rule that has served me well; I’ve never had an STD, despite a huge number of partners.
PrEP – while undeniably a good thing – is very disorienting. Do I avoid barebackers who use PrEP? Just continue using condoms with them? Start taking PreP myself and forgo condoms altogether? What a wonderful, frightening thought that is.
I know I should be celebrating. Instead I’m still worrying … about a new set of issues.
Those two adjectives – “wonderful” and “frightening” – say it all. Fear is a terribly difficult thing to leave behind, especially when you have lived your entire life in its shadow.