The Madness of HIV PrEP UPDATED

PrEP stands for pre-exposure prophylaxis, and it simply refers to medicating someone before they get sick. I’ve had to do this myself by taking antibiotics prior to dental work. It’s not uncommon.

The search for a magic bullet to prevent HIV infection is driving people to try radical solutions that may, in fact, make matters worse. The FDA is about to approve the combination drug tenofovir-emtricitabine (marketed as Truvada) for PrEP in order to reduce transmission of HIV. The drug has the potential of reducing the risk of HIV infection by 44%, and perhaps as much as 73%.

I don’t know about you, but I don’t really like those odds.

Meanwhile, Standford University has been trying to determine the cost-effectiveness of providing the drug to high-risk gay men who are likely to have a lot of unprotected sex.

They calculated that providing the pill to the entire sexually active gay male population would cost half a trillion dollars over 20 years. But by targeting just the most promiscuous gay men (defined as 5 or more partners per year), they could knock that cost down to a mere $85 billion.

In developing their model, the Stanford researchers took into account the cost of the drug — about $26 a day, or almost $10,000 a year — as well as the expenses for physician visits, periodic monitoring of kidney function affected by the drug, and regular testing for HIV and sexually transmitted diseases.

“We’re talking about giving uninfected people a drug that has some toxicities, so it’s crucial to have them monitored regularly,” Bendavid said, who is also an affiliate of Stanford Health Policy, which is part of the Freeman Spogli Institute for International Studies.

Without PrEP, the researchers calculated there would be more than 490,000 new infections among the MSM population in the United States in the next 20 years. If just 20 percent of these men took the pill daily, there would be nearly 63,000 fewer infections.

However, the costs are substantial. Use of the drug by 20 percent of the MSM population would cost $98 billion over 20 years; if every man in this group took PrEP for 20 years, the costs would be a staggering $495 billion.

Given these figures, the researchers looked at the option of giving PrEP only to men who are at high risk — those who have five or more sexual partners in a year. If just 20 percent of these high-risk individuals took the drug, 41,000 new infections would be prevented over 20 years at a cost of about $16.6 billion.At less than $50,000 per quality-adjusted life year gained (a measure of how long people live and their quality of life), that strategy represents relatively good value, according to Juusola.

“However, even though it provides good value, it is still very expensive,” she said. “In the current health-care climate, PrEP’s costs may become prohibitive, especially given the other competing priorities for HIV resources, such as providing treatment for infected individuals.”

So we’re seriously considering funding prophylactic drugs to enable gay men to have lots of high-risk sex, but with a potential failure rate higher than 50%? We’re debating whether or not  grandma might have to just take a pill instead of having life-extending surgery, but also considering an expensive, semi-effective, potentially toxic prophylactic treatment that encourages dangerous behavior? How does this make any sense at all?

I searched in vain for some indication that the authors of the Stanford study understood the psychological effect of giving sexually active, highly promiscuous gay men the idea that they’re essentially invulnerable, and the radical increase this will cause in high-risk behavior: an increase that must certainly offset the drug’s effectiveness.  Any drug that is less than 100% effective stands a very high chance of creating more problems because it will lead to an increase in dangerous behavior.

The FDA approval for this use of Truvada is irresponsible, since it will push Medicare, Medicaid, and the insurance companies to cover the drugs for PrEP purposes, adding a huge new burden to the already-strained healthcare system. This means that men who don’t have HIV, but wish to engage in high-risk sexual activity, will be playing Russian roulette with a drug that doesn’t even work half the time.

I understand the horrors of death by AIDS. I had the misfortune of seeing it up close with someone I loved dearly. But our desire for a solution to this scourge shouldn’t cloud our common sense. New HIV infections are 100% preventable, but the solution is not chemical: it’s behavioral. That’s been the hard truth at the heart of this epidemic from the beginning.

From a Catholic perspective, there are various issues at war in the fight against AIDs. Even a masterful teacher like Benedict XVI was misunderstood (perhaps deliberately by some) when he said:

There may be a basis in the case of some individuals, as perhaps when a male prostitute uses a condom, where this can be a first step in the direction of a moralisation, a first assumption of responsibility, on the way toward recovering an awareness that not everything is allowed and that one cannot do whatever one wants.

This was not the “Pope Approves Condoms!” headline of the mass media, but a far more subtle point: that a person engaged in multiple instances of immoral behavior may be showing some flicker of conscience when he uses a condom to prevent disease transmission (thus showing concern for the life of another), and that this flicker may be the first step to “recovering an awareness that not everything is allowed and that one cannot do whatever one wants.”

Promiscuity is a sin whether the sex is gay or straight. As a married man, I can no more have sex with numerous women without grave moral (and perhaps physical) consequences than a gay man can have sex with numerous men without those same moral and physical consequences. In the case of the gay man, the physical consequences are likely to be much, much higher. A drug that reduces those potential consequences has two moral factors. The first is the reduction of disease transmission, which can be a moral good. But the second is a potential increase in the immoral behavior that leads to the disease transmission in the first place.

The issue is a challenging one for the church, as Pope Benedict well understands:

One cannot overcome the problem [of AIDS in Africa]  with the distribution of condoms. On the contrary, they increase the problem.

The solution can only be a double one: first, a humanization of sexuality, that is, a spiritual human renewal that brings with it a new way of behaving with one another; second, a true friendship even and especially with those who suffer, and a willingness to make personal sacrifices and to be with the suffering. And these are factors that help and that result in real and visible progress.

Therefore I would say this is our double strength — to renew the human being from the inside, to give him spiritual human strength for proper behavior regarding one’s own body and toward the other person, and the capacity to suffer with the suffering.

He also had this to say:

The problem of AIDS, in particular, clearly calls for a medical and pharmaceutical response. This is not enough, however: the problem goes deeper. Above all, it is an ethical problem. The change of behavior that it requires – for example, sexual abstinence, rejection of sexual promiscuity, fidelity within marriage – ultimately involves the question of integral development, which demands a global approach and a global response from the church. For if it is to be effective, the prevention of AIDS must be based on a sex education that is itself grounded in an anthropology anchored in the natural law and enlightened by the word of God and the church’s teaching.

The end of AIDS comes not merely with mechanical or chemical solutions, but with a better understanding of our moral natures and the way we use our bodies, and that’s a very hard thing to convey in a fallen society.

UPDATED

At Unequally Yoked, Leah takes issue with this post. In “When Moral Hazard is the Safest Course“, she makes a good case for accepting “moral hazard” as a reasonable price for protecting the public health. I feel like I acknowledged this, to a degree, with my point about Benedict and condoms, but it’s part of a much more subtle moral argument. Protecting the health of others while committed an immoral act does not lesson the immorality of the act, but shows a moral awareness on the part of the actor. I don’t feel like the risk of HIV is some kind of “corrective” against immoral behavior, and I never have.

Here’s Leah’s main point:

Unlike McDonald, I think same-sex relationships are morally neutral, so aiding and abetting them isn’t a problem for me.  (I’ve got more qualms about hookup culture and promiscuity, whatever the match-up).  But even granting some of his premises, I can’t believe that the right way to approach sexual ethics is to just make it much more risky and deadly.  The FDA recommends Truvada because it’s better for the people taking iton net.  That means the moral hazard of more sex is outweighed by the lower transmission rates, even factoring in more sex.

That means you’d better be really confident that it’s worse for people who are engaged in behavior you condemn to be healthier than to be sick.  You’d better have data that makes it clear that their suffering will actually motivate a change in behavior (and, in this case, you need to persuade people that homosexuality is harmful in the first place).  Otherwise, like the people who reject Vancouver’s safe zone for drug addicts, you sound like you’re really trying to restore some kind of cosmic balance, where people who do bad things need to have bad outcomes, even if we have the power to protect them.

And here’s my response:

I made sure I separated the two main issues here. I called reducing disease transmission a “moral good.” It’s irrelevant whether I approve or don’t approve of the activity in question: protecting the human individual from disease is always a moral good. The second issue, of course, is the activity in question, which is not “good.” I think Benedict’s point about a male prostitute who uses a condom to protect a human life holds here: it shows a moral awareness of the preciousness of all life. A person isn’t condemned to death because of a poor moral choice.

However, I want to draw the focus back to my main point, which you seem to be downplaying: that is, the psychological effect of the drug. I’ve seen some studies showing very high rates of success with perfect use, but these are small, controlled studies where people are well-instructed and monitored. When the drug makes its way into general use, several major problems arise.

First, if people feel they are “protected” against HIV, they will be less cautious and engage in more high-risk behavior. How does this increase in high-risk behavior offset the effectiveness of the drug? I’m not at all assured by studies that show effectiveness as low as 44%, and by focusing on the higher effectiveness rate, you seem to be downplaying this very real risk.

Second, the drug can be extremely toxic. It requires constant monitoring and can damage the user’s health, which brings us to the third point: the drug is being taken as a hedge against lethal disease so that people can engage in high-risk sexual activity. I take a potentially lethal drug so I can walk and use my hands. I know others who take potentially lethal drugs so they don’t die. Obviously, we have a different perspective on this issue, but drugging yourself (at no small expense to the State and the insurance companies) so you can engage in certain sexual activity seems like madness, and making others pay for it is doubly so.

UPDATE II: Just took a look out the window, and a pig went flying by. Yep, I agree with Dan Savage about something. And the New York Times is raising the same concerns.

By the way, I don’t like applying the term “moral hazard” in cases like this, since there are moral issues involved which are separate and distinct from traditional moral hazard arguments. Not all “moral hazards” are immoral by Catholic standards. For instance, taking statins while continuing to eat fatty foods is not immoral, just stupid. (Guilty!) Using moral terms when you’re really referring to psychological or behavioral issues tends to muddy the waters.

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About Thomas L. McDonald

Thomas L. McDonald writes about technology, theology, history, games, and shiny things. Details of his rather uneventful life as a professional writer and magazine editor can be found in the About tab.


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