There is a recent publication in the NEJM titled: Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. A very scholarly and well constructed blog-commentary was just written on this by my colleague, medical blogger extraordinaire and very good friend, Dr. Michael Edmond.
In brief, the investigators assigned 2499 HIV negative men or transgender women who have sex with men to receive a combination of two oral antiretroviral drugs or placebo once daily. All subjects received HIV testing, risk-reduction counseling, condoms, and management of sexually transmitted infections. After a maximum of 2.8 years in follow up, a 44% relative reduction in the incidence of HIV was detected in those taking the antiretrovirals. The absolute risk reduction was only 2.4%.
I am by no means conservative and generally welcome new perspectives and ideas to challenging medical problems, however, I simply cannot get excited about this study.
My reasoning is as follows:
- The findings may be efficacious in a controlled study but will likely not be effective in the real world. Why?
- Adherence to medications is always a problem, without oversight from study personnel, adherence in the real world will be less than ideal, compromising the protective effect off the antiretrovirals
- Antiretrovirals have side effects, further compromising efficacy.
- In the event that there is poor adherence, prolonged, erratic use of antiretrovirals will lead to drug resistance, compromising the efficacy of treatment when one does have HIV/AIDS
- This strategy is costly. Antiretrovirals cost $10,000 + per annum. Will third party payers allocate valuable resources for ‘preventive’ antiretroviral services when other preventive measures such as mammography, colonoscopy, cholesterol screening and smoking cessation programs, all of which are already underutilized, are likely to have a greater population based health effect?
- This strategy will only work for people who have insurance and access to healthcare. The
Perhaps we should aggressively promote safe sex, condom use, and universal testing for HIV in all medical settings.
Call me old fashioned.
