Friday, December 19, 2014
FAIRFIELD-SUISUN, CALIFORNIA
99 CENTS

Pre-exposure prophylaxis for HIV may confer risks

scott column sig

By
From page B10 | June 28, 2014 |

One of the arguments for needle-exchange programs in intravenous drug users is “harm reduction,” or mitigation of risk associated with some unhealthy behaviors.

Unintended consequences may result from such efforts. For example, needle-exchange programs, or methadone use, may contribute to addictive behavior. In a similar way, legalization of drugs, designed to minimize the adverse effects of crime and drug trafficking, may facilitate drug dependence.

Pope Francis, admittedly a religious figure and not a public health expert, recently expressed his concerns with regard to drug-legalization while speaking to a forum of drug-enforcement experts in Rome. He said, “The problem of drug use is not solved with drugs.”

Law enforcement officials sometimes express a similar view. When I was a resident in the 1980s, then-District Attorney Rudolph Giuliani spoke to us at an event at Cabrini Medical Center, in Manhattan. Giuliani opposed legalizing drugs, citing an increase in rates of liver cirrhosis that occurred after alcohol prohibition was overturned in 1931. Many people, it turned out, did abide by the laws of the prohibition era, contrary to popular perceptions. Legalizing drugs, therefore, would likely fail as a harm-reduction strategy, as drug use might similarly increase in such a setting, with detrimental consequences.

A recent debate reminded me of Giuliani’s cautionary comments, and the difficulty of promulgating health recommendations.

Authorities previously recommended abstinence, or the use of latex condoms, as prevention strategies with respect to HIV. Now a different approach is emerging. Outlined in a recent article in the San Francisco Chronicle (“HIV prevention therapy slowly gains acceptance,” by Erin Allday), this strategy involves the use of Truvada, an anti-viral medication directed against HIV. Daily use of Truvada as “pre-exposure prophylaxis,” or “PrEP,” decreases the risk of acquiring HIV by as much as 90 percent among men who have unprotected sex with other men, we are told. Allday suggests that such Truvada prophylaxis might “nearly eliminate the risk of contracting HIV.”

You can count me among the physicians who are skeptical of this approach to disease prevention. Let me explain my specific concerns.

If men, having sex with men, feel protected by a medication of this sort, promiscuity will be encouraged. Indeed, one of the subjects in the article describing this form of prophylactic treatment proudly wears a T-shirt identifying himself, in his words, as a “Truvada whore.”

Any putative 90 percent reduction in harm is likely to be diminished if the users of Truvada increase their numbers of sexual encounters on an otherwise unprotected basis. Moreover, even if Truvada were to prevent HIV, it does so among a cohort that is seeking an alternative to latex condoms, which afford protection against other sexually transmitted diseases.

Consequently, other infectious diseases are likely to become more prevalent to the extent that PrEP gains currency. These STDs include syphilis, gonorrhea and human papillomavirus infection, which causes anal cancer. Prophylaxis with Truvada, therefore, may come at a high cost in terms of the overall health of gay men, as well as among the community at large.

When I was an Air Force physician, I learned about “no show pills,” antibiotics prescribed to men who were going on leave in foreign cities. The idea, which I did not employ in my own medical practice, was to medicate men prophylactically to prevent gonorrhea from emerging, in the wake of prostitution-related encounters.

Such prescription practices, as well as similar protective use among sex workers, probably contributed to the emergence of resistant strains of gonorrhea over the past several decades. The profligate use of Truvada might similarly lead to the development of resistant strains of HIV. Harm reduction strategies, if misguided, may cause more harm than good.

Scott T. Anderson, M.D., Ph.D. (stamdphd@comcast.net) is clinical professor of medicine, University of California, Davis. This column is informational, and does not constitute medical advice.

Scott Anderson

LEAVE A COMMENT

Discussion | 2 comments

The Daily Republic does not necessarily condone the comments here, nor does it review every post. Read our full policy

  • Jiveinthe415June 29, 2014 - 9:50 am

    If a medical doctor is going to proffer a medical opinion, we expect that the medical advice will be based on science and scientific evidence. Dr. Anderson chose to offer an opinion based on his personal anti-gay animus, and his experience doling out antibiotics to horny Air Force personnel. Dr. Anderson wrote that "Prophylaxis with Truvada, therefore, may come at a high cost in terms of the overall health of gay men." I hate to break the news to you Doc, but gay men have been having sex from time immemorial, and each year more people are infected with HIV. I have a few issues with your hypothesis. The first is that you didn't investigate exactly what the treatment protocol involves. You are assuming that anyone who goes on PrEP is going to engage in unsafe sex. Read the UCSF study before you make stupid assumptions. You are wrong. What really makes me angry is the fact that you made a generalization about the gay community, and said "the profligate use of Truvada might similarly lead to the development of resistant strains of HIV." There is NO evidence that resistant strains of HIV will develop because of Truvada. You make the same argument against Truvada use, that some in the medical community made about birth control pills. Medical doctors claimed that women would be more promiscuous because birth control pills would be readily available. You are showing a very strong anti-gay bias, and that's something you need to look at. Truvada has a good chance of reducing HIV infections, and that's a good thing. HIV still kills Dr. Anderson, and any effort to reduce infections should be applauded. Roy Steele jiveinthe415.com

    Reply | Report abusive comment
  • Scott AndersonJuly 01, 2014 - 9:30 pm

    July 1, 2014 Dear Mr. Steele: Every column I write ends with the words, “this column is informational and does not constitute medical advice.” My concerns, perhaps not expressed very artfully, were generic and not specific to any particular patient. I am sorry to hear that you took such offense to my comments. The question, as I see it, is whether pre-exposure prophylaxis for HIV, as outlined in the SF Chronicle article of last month by Erin Allday, might prove potentially harmful. Could HIV exposure rates increase, along with exposure to other pathogens, if condoms are abandoned in favor of prophylactic pill use? Such concerns are hardly homophobic. Indeed, the Chronicle article cited similar skepticism emanating from the AIDS Healthcare Foundation. With respect to disparaging gays, the SF Chronicle article is replete with offensive terms, such as “slut-shaming,” “Truvada whore,” and “party drug,” in its description of gay sexual politics. My article contained no similar polemics. Your letter contains harsh language as well, disparaging military personnel as “horny,” and calling me “stupid.” Those comments do not advance civility, or reason. You also misconstrued my expressed stance on “doling out antibiotics” indiscriminately. I am against the overuse of antibiotics, because such practices breed drug resistance and false complacency. Thank you for writing, and prompting me to look carefully at my original article. I think we share a goal of improving the health care status of our friends and family in the Bay Area. Cordially, Scott T Anderson, MD, PhD

    Reply | Report abusive comment
.

Solano News

 
Groundbreakings, ribbon-cuttings play role in civic life

By Barry Eberling | From Page: A1, 1 Comment | Gallery

Sondheim’s ‘Woods’ holiday showcase for Missouri Street Theatre

By Amy Maginnis-Honey | From Page: B1 | Gallery

 
Frankye Kelly ready to spread holiday cheer

By Amy Maginnis-Honey | From Page: B1

 
Celebrate the magic of Christmas

By Tony Wade | From Page: A2, 2 Comments

 
 
Safe streets task force work nets 3

By Ryan McCarthy | From Page: A3, 5 Comments

Santas have busy week at schools

By Susan Hiland | From Page: A3, 2 Comments

 
Solano College approves officers, meeting schedule

By Susan Winlow | From Page: A4

Longtime Suisun harbor master to retire

By Ian Thompson | From Page: A4, 2 Comments

 
 
 
Suisun City police log: Dec. 17, 2014

By Susan Hiland | From Page: A12, 1 Comment

 
Fairfield police log: Dec. 17, 2014

By Susan Hiland | From Page: A12

 
.

US / World

Next steps on Cuba: Normalizing could take awhile

By The Associated Press | From Page: A1

 
Sony hacking fallout puts all companies on alert

By The Associated Press | From Page: A1

Sony film took aim at North Korea’s biggest taboo

By The Associated Press | From Page: A1, 4 Comments

 
Timeline of the Sony Pictures Entertainment hack

By The Associated Press | From Page: A1

Digital dilemma: How will US respond to Sony hack?

By The Associated Press | From Page: A1

 
Spy’s parents search for son after Cuba-US deal

By The Associated Press | From Page: A1

 
Hope and some fear in Cuba amid thaw with US

By The Associated Press | From Page: A1

California’s top utility regulator defends record

By The Associated Press | From Page: A5

 
‘Pretty horrible’ scene; car slams into crowd

By The Associated Press | From Page: A5

 
Police: Drunk man shot while entering wrong house

By The Associated Press | From Page: A5, 4 Comments

 
Local emergencies in Northern California counties after rain

By The Associated Press | From Page: A5

Tsarnaev appears in court for 1st time since 2013

By The Associated Press | From Page: A6

 
President signs legislation ending Nazi benefit checks

By The Associated Press | From Page: A7

2 states challenge Colorado marijuana legalization

By The Associated Press | From Page: A8, 3 Comments

 
‘Prison Houdini’ set to make his 1st legal escape

By The Associated Press | From Page: A8

 
Feds sue NYC over Rikers Island jail violence

By The Associated Press | From Page: A8

Russian sailors leaving France without warship

By The Associated Press | From Page: A9, 2 Comments

 
Putin: West wants to defang, declaw Russian bear

By The Associated Press | From Page: A10, 2 Comments

Suspected Islamic extremists kidnap 185 in Nigeria

By The Associated Press | From Page: A13, 2 Comments

 
European court rules obesity can be a disability

By The Associated Press | From Page: A13

.

Opinion

News of the day strikes a chord

By Bud Stevenson | From Page: A11, 10 Comments

 
 
Another look at school bonds

By George Guynn Jr. | From Page: A11, 5 Comments

Editorial Cartoon: Dec. 19, 2014

By Daily Republic Syndicated Content | From Page: A11

 
.

Living

Today in History: Dec. 19, 2014

By The Associated Press | From Page: A2, 1 Comment

 
Community Calendar: Dec. 19, 2014

By Susan Hiland | From Page: A2

Horoscopes: Dec. 19, 2014

By Holiday Mathis | From Page: D8

 
Should I use Child Protective Services threat to get back rent?

By Kathy Mitchell and Marcy Sugar | From Page: D8

.

Entertainment

Week in preview Dec. 19-25, 2014

By Amy Maginnis-Honey | From Page: B1

 
Sweet ‘Night at the Museum’ bids farewell to Robin Williams

By The Associated Press | From Page: B2

 
Craig Ferguson to end 10 years as host of ‘Late Late Show’

By The Associated Press | From Page: B3

Eric Idle brings ‘Not the Messiah’ to Carnegie Hall

By The Associated Press | From Page: B3

 
Entertainment calendar Dec. 19, 2014

By Susan Hiland | From Page: B4

.

Sports

Warriors beat Thunder 114-109 after Durant injury

By The Associated Press | From Page: B7

 
A’s acquire lefty De La Rosa from Arizona for cash

By The Associated Press | From Page: B7

 
Raiders defense depleted by injuries

By The Associated Press | From Page: B7

49ers’ Harbaugh mum on reported offer from Michigan

By The Associated Press | From Page: B7

 
49ers’ Aldon Smith hopes to build off tough year

By The Associated Press | From Page: B7

A’s trade All-Star catcher Derek Norris to Padres

By The Associated Press | From Page: B7

 
Celtics trade Rondo to Mavericks

By The Associated Press | From Page: B8

Rodriguez boys open Les Curry Tournament with victory

By Daily Republic staff | From Page: B8

 
39 bowl games and a reason to watch every one

By The Associated Press | From Page: B8

Column: Thaw in US-Cuba relations warms up MLB

By Jim Litke | From Page: B8

 
Rivera: Newton ‘probably’ will start vs. Browns

By The Associated Press | From Page: B8

Bears bench QB Jay Cutler for Clausen

By The Associated Press | From Page: B8

 
‘Hands Up’ players to attend Ferguson Christmas party

By The Associated Press | From Page: B8

Signups for Friday, Dec. 19, 2014

By Paul Farmer | From Page: B9

 
This date in sports history for Friday, Dec. 19, 2014

By The Associated Press | From Page: B11

Sports on TV/Local sports for Friday, Dec. 19, 2014

By Paul Farmer | From Page: B11

 
.

Business

Roomiest Subaru Legacy debuts for 2015

By Ann M. Job | From Page: C1

 
Ford expands drivers air bag recall nationwide

By The Associated Press | From Page: B6

Constantly changing online prices stump shoppers

By The Associated Press | From Page: B6

 
Dow industrials have their best day in three years

By The Associated Press | From Page: B6

.

Obituaries

Lisa Dee McHughes

By Nancy Green | From Page: A4, 1 Comment

 
Travis Curt Price

By Susan Hiland | From Page: A4, 1 Comment

Ernest “Ernie” Moretti

By Nancy Green | From Page: A4

 
Jennie Ponce Reyes

By Nancy Green | From Page: A4

Patricia “Pat” Anne Stringfield-Pierre

By Nancy Green | From Page: A4

 
.

Comics