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Pre-exposure prophylaxis for HIV may confer risks

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. ([email protected]) is clinical professor of medicine, University of California, Davis. This column is informational, and does not constitute medical advice.

Scott Anderson


Discussion | 2 comments

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  • 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

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  • 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

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