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.


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.

  • victor

    Someone definitely needs to familiarize the FDA with the term “moral hazard”. But then, that would require that this adminstration has any economists on staff.

  • Brian Green

    Excellent example of a problem with two solutions: one technological and one moral. And of course the moral one couldn’t actually be proposed as a possible solution because, well, who wants to be moral? Just lay on the technology and we can just keep making the same poor choices as before, just without the bad consequences (maybe). Seek salvation through technology, not by actually controlling oneself. Never mind that technology fails. This path (and it is a path being trod in many fields, not just sexuality) can only turn out badly.

  • Fr Levi

    Great article. That such an stupid idea would be given serious consideration by so-called ‘experts’ speaks volumes about the superficial nature of modern society … this is where ‘progress’ has brought us.

  • lethargic

    We will be paying for all of this … thanks Obama

  • ccm2100

    While I agree with most of what you say, you are missing the pointer that Truvada as PrEP may be close to 100% efficacy with strict adherence. See here
    The numbers you mention correspond to poor adherence rates of the drug, therefore reduced efficacy.

    My concerns with this are also the side effects of this drug to perfectly healthy people. I haven’t seen it anywhere, but AFAIK HIV drugs have a long list of side effects.

    And for the contributor here who was blaming Obama about this… please, let’s stop politicking every single thing out there. I’m sure that Gilead trying to make money out of Truvada is probably more the source of all this discussion.

  • marc

    perhaps I could see this for sero-discordant couples… but for all gay men who aren’t in monogamous committed relationships? I don’t think so… and question? Are there any of those? I thought I had one, but no he wasn’t and he didn’t stand by me when I needed him most.

  • Ken

    You lost me at “a fallen society.” Take your bankrupt morality that condemns us all to pain and suffering for someone else’s sin from long, long, long ago, and just go away. You have nothing relevant to say here.

  • Thomas L. McDonald

    “Go away”? YOU came HERE.

    As for the fallen nature of man, I don’t have to go back “long, long, long ago” to know that humanity is fallen. I don’t have to go back any further than this morning’s headlines.

  • Smidoz

    “Take your bankrupt morality that condemns us all to pain and suffering for someone else’s sin from long, long, long ago, and just go away.”

    Well, since this will all cost the tax payer, one could argue that promiscuity, whether you see it as immoral or not, is going to cost even those Americans who aren’t promiscuous, what about condemning people for the sins of others? America may have pulled off a really good economic recovery over the last few years, can it really go throwing money after people, gay or straight, who choose to engage in risky behaviour?

  • Brandon

    For instance, taking statins while continuing to eat fatty foods is not immoral, just stupid.

    In a land where medical costs tend to be societal rather than borne strictly by the individual, how is this not an immoral action? If the argument is that its morally incumbent on individuals to reduce risky behavior because of the burden on society, it stands to reason that it applies just as much to a high risk diet as it does to high risk sexual activity.

  • Thomas L. McDonald

    I never used a “burden on society” argument for immoral behavior, nor would I. Contagious, sexually transmitted and transmittable diseases are not the same thing as diet. Food is necessary, while sex is optional. The poor often cannot afford low-fat foods or healthy diets because of cost and where they live. (It’s cheaper and easier to eat fast food than to make a healthy meal.) There’s no moral equivalence whatsoever.

  • Brandon

    I follow what you’re saying, but where does this line of thinking stop? If increasing risk of higher health care costs is, ipso facto, an immoral activity, are any and all activities that carry risk factors immoral? What about simple lack of activity, which carries increased risk of disease? Am I committing an immoral action on any day that I choose to not go for a run?

    I suppose there’s an argument that can be made that this is, in fact, the case. It’s not one that I’m prepared to buy though; perhaps gross negligence is immoral, but I don’t think morality can be quantified in a straightforward fashion that allows us to declare any single action that has associated risks as immoral.

  • Brandon

    It seems to me that there’s a bit of a bait and switch pulled when you state that food is necessary; of course it is, but no one was talking about not eating food at all, we were talking about high fat foods, which are surely no more essential than sex (and quite possibly less essential).

    If the societal burden argument isn’t part of your point at all, my mistake though. Anything I say past that is really semantics, since my comment doesn’t address your point.

  • Thomas L. McDonald

    I’m pretty sure I never made that particular argument of increasing health care costs being immoral. My only monetary point was that society has no interest in paying people to have high-risk sexual encounters. Nor does it have any interest in paying for people’s abortions or contraception, botox, viagra, clean drug needles, or similar “optionals.” I understand the arguments in favor of these, but I don’t agree with them.

    Even the high-fat food isn’t really an equivalent argument, because lifestyle can only impact cholesterol by about 10-15%. The rest is genetics.

  • Brandon

    My intention, in the post above, was to address Smidoz’s comments. If I gave the impression that this was targeted to your post, my mistake.

    Suffice it to say, I disagree very strongly with the idea that society has no compelling interest in paying for drugs that mitigate long run health costs. I’m not convinced that this treatment does (or doesn’t) do that, but I think it’s a generally good policy to attempt to minimize expenditures while maximizing health.

    [TLMcD: My mistake: I don't see the messages in a chain or on the page, just as a message.]

  • Ken

    Not buying the “fallen society” crap. I did not do anything to merit the pain and suffering supposedly inflicted upon this corrupt world. And if I am being punished for Eve’s sin, God can just go fuck off and abandon any pretense of being “just” and “forgiving.”

  • Ken

    And the alternative is…? What is the current cost of AIDS treatment through terminal stages vs. the cost of this drug? I guess we should just line up the garbage trucks to go down the street and we’ll drag the bodies out to the curbs like in the good old plague days. That show those fags something about God’s goodness. The “who pays for it” argument is a diversion — who is paying for the treatments now, and could we actually cut costs by cutting down on the numbers of infected needing treatment? I don’t know, but since God isn’t answering my calls, I throw the question out here.

  • Thomas L. McDonald

    No need to drag Adam and Eve in this. If they hadn’t sinned, Abel would have. And if he hadn’t, I would have. We have our choices. We know the right ones and wrong ones. And still we make the wrong ones. Original sin isn’t the punishment of all humanity for the sin of one person. It’s the separation of man from God by an act of will, and we keep doing it every day.

  • Ken

    Bullshit,by any other name.

  • Thomas L. McDonald

    I tried being civil despite your aggressive tone and consistent use of obscenity. Clearly, you are incapable of rational dialog or even a tiny amount of civility, so don’t bother posting any further. Your comments will be deleted.

  • Smidoz

    Ken, I feel like I’m taking a bit of a cheap shot knowing that you probably won’t be able to reply, but since your criticism is a common one, it probably does warrant a reply.

    Not doing bad stuff doesn’t make you worthy or deserving of anything, and I have to say that to claim that you’re being punished for Eve’s sin is somewhat self righteous, I’m sure you’ve not lived the perfect life, but perhaps I’m wrong. Most critics of the Bible have a focus on the “thou shalt nots,” and forget about the “do goods,” “do good for those who hate you,” “pray for your enemy” and all that stuff. Yes, the world we live in sucks, there’s pain and suffering, and that sucks; people go to war, and that sucks; people treat each other like rubbish, and that sucks; people starve, and that sucks. In all, the fact that you and me and everybody else in this thread are fortunate enough to be using a computer; tablet or smartphone, means we probably don’t understand the suffering that those who don’t know if they’ll be having a meal tonight or not, experience. But not doing bad things doesn’t inherently make you a good person, there is suffering in the world because it is acceptable, there is no 99%, or 1%, there are those who have more than they need, and those who don’t. There will be death, sure, but the world doesn’t need to be half so bad as it is, but ultimately it’s up to people, as a general group, to stand up and say, “we’re tired of this, and we’ll make that difference. No benevolent God could force that onto people, that would make God a tyrant, and benevolent tyrant is an oxymoron.

    I’ve gone on too much, but ultimately, stop complaining about how bad the world is, and start asking what you can do to make a difference, start a blog; write about your issues; offer solutions; start a photo blog, raise awarenes of the injustice in the world; donate money; donate time. There is so much people can do without coming onto a reasonable discussion forum and criticaising those who are willing to step up and put themselves out there because they want to make a difference. Swearing about how miserable the world is doesn’t help.

  • Smidoz

    The first part of my comment was simply to show an inherent double standard in Ken’s thinking, if he’s angry at God, or Eve, for the circumstances in the world today, why isn’t he angry at the state, or the people who will benefit from this program for much the same reason? We don’t live in a void, and our actions do affect others, this is something that we must deal with, rather than blaming one person; God, or anyone else, perhaps we should examine how our own behaviour, or the behaviour of those we support, affects the world.

    The second part of my comment was a question, I realise why it would have been seen as rhetorical, I apologise for the mix up, I’m a South African, and actually don’t know whether America can afford it or not. That said, I do think that we can quantify morality on the effects on society as a whole. Social well being seems to be about the only completely universal (in time and space) moral imperative, if you know of others, I’d be very interested to know. Perhaps promiscuity can be viewed as immoral on these grounds due to STDs, and perhaps not doing something to prevent them can also be viewed as immoral, on the same grounds. I do take issue with the fact that only high risk gay men should be getting the government funded benefit, which I’ll address below.

  • Smidoz

    I’m not for people dying, as your poor analogy to the plague implies. Don’t have irresponsible sex, and you’ll greatly increase your chances of not getting aids, really, no cost. You use the word “fags” as if to imply I have an issue with the fact that I don’t want gay people helped, no, I dislike the fact that the more high risk, ie. the less responsible, the more the government should help you, is that really fair, gay or straight. Why should it be gay men though, why not high risk hetro women? I fail to see how allowing a group an out based on their gender isn’t predujicial. Why don’t they just go for high risk individuals.

    You claim that the cost is a diversion, but the real diversion is pretending the problem is with gays, if it were any other group, the issues would be the same, should we give people ticket to be irresponsible?

  • enness

    Wow. The lengths to which we will go to avoid the discomfort of telling people something they don’t want, but desperately need, to hear…the sheer mental gymnastics…

  • Godless

    When are we going to face the truth that it is unhealthy and unrealistic to believe that it is possible for any of us to deny our sexuality? Just as most parents allow their daughters to take birth control, even though they may prefer they wee abstinent, we should allow this treatment to prevent HIV from being spread. You say that the cost will be prohibitive? I think that if enough people stood up for a change, and demanded affordable drugs, it would not be an issue. Or maybe it is more comfortable for you look down from your moral pedestal and continue to watch us “sinners” die. People like you are exactly the reason I have no faith in Jesus. You make me weep for humanity.

  • Thomas L. McDonald

    There’s no point in replying since you either did not read, or did not understand, what I wrote.