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.