Condom Clash Health Workers Fight Over a Magic Little Pill That Could Prevent HIV Infection

Mike Force

Gay men: What if I told you there's a pill that could cut your chance of becoming HIV positive by 44 percent or more? Because that pill already exists. It's called Truvada.

Truvada is part of what's commonly known as the AIDS cocktail—the daily multidrug treatment regimen given to HIV-positive people. In July, the Federal Drug Administration green-lit Truvada as a preventative pill—or pre-exposure prophylaxis (PrEP) treatment—for people at high risk for HIV infection. Now a clinical trial at the University of Washington is studying whether another AIDS cocktail drug, Maraviroc, could also be effectively prescribed as an HIV prevention pill for high-risk groups.

"It's a radical, transformative, powerful tool, and we know that it works," explains Michael Louella, outreach coordinator for the University of Washington's AIDS Clinical Trial Unit, who's currently recruiting 400 gay men and transgender women in Seattle to test the side effects of Maraviroc.

But Louella has managed to find only two willing participants for his UW trial, in part because he says the health providers who work with his target study groups are more concerned with the drug's potentially disastrous consequences, if the pill replaces condoms in gay men's sexual toolbox, than with its benefits. They point out that without condoms, other STDs will proliferate—and syphilis and genital herpes are already on the rise. They worry that prescribing it to HIV-negative men will make them resistant to first-line treatments, should those men contract HIV. They worry that misuse of these expensive pills could help create a drug- resistant form of the virus. And they warn that the drug is too expensive (up to $9,000 a year) for casual preventative use.

"It's an expensive prevention/intervention method, and there are already waiting lists in many states for these drugs," admits Dr. Joanne Stekler, deputy director of the Public Health Seattle & King County HIV/STD program. "Providers worry about the competing priorities of at-risk populations and those who are already HIV positive."

"My concern is, we have lots of opinions about what these drugs can do, but limited data," says Steve Wakefield, director of the Legacy Project, which seeks to increase participation in HIV vaccine trials among people of color. Wakefield says he's not against PrEP, but at this stage, he wouldn't recommend it for most of his clients. "The politics around this new invention are as askew as the politics guiding the early days of women's birth control. It would be unethical to tell people not to use condoms."

But Louella says that some gay men are already dosing themselves with PrEP to prevent infection, in so-called party packs illegally sold at gay dance clubs. "Men pay for three pills: an HIV medication like Truvada, combined with Viagra and ecstasy or meth." (Healthcare providers caution that these HIV meds are not the gay male equivalent of the morning-after pill—you can't take them once and expect it to be effective.)

"For 30 years, the consensus has always been condoms equal safe sex," Louella says. But in his opinion, that message "clearly isn't working" because roughly 50,000 people in the United States, including 330 King County residents, are annually infected with HIV. Those numbers have held steady for nearly two decades and predominantly affect gay and minority populations. (For example: 28,782 gay adult and adolescent men contracted HIV in 2010, according to the Centers for Disease Control and Prevention, while only 12,875 straight men and women became infected.)

"But if you regularly take a pill for HIV, it could be that people don't need to use condoms—that the pill is safer sex," Louella adds. "And that's scaring the bejesus out of people."

In 2010, a study of 2,499 men and transgender women who had sex with men was jointly conducted in six countries. The study directed participants to take Truvada daily. After 1.2 years, the HIV infection rate for the study group had been lowered by 44 percent. What's especially significant is that most of the failures in prevention seemed to occur when people didn't take the pill as directed. A small substudy found that risk of infection plummeted by 92 percent in people who had measurable levels of the drug in their blood—i.e., they were regularly taking the pill every day instead of sporadically before or after a sexual encounter.

"Imagine cutting Seattle's infection rate by 44 percent," says Louella, who puts Seattle's infection rate at 300 people per year. "That's 123 people, most of them gay men. That's not insignificant."

Still, the threat that gay men will dismiss the many benefits of condom use as these medications become more widely available is real and persistent. A gay man who didn't wish to have his sex life identified in The Stranger told me this anecdote: "I met a guy recently who offered to have unprotected sex with me. I said I was HIV negative and that I didn't do that. So we had wonderful sex, with a condom, for 45 minutes. Afterward, I asked why in the hell he'd do that—have unprotected sex with a stranger? He said, 'Well, I'm on PrEP.' These drugs could create a whole new world where people on PrEP are even less concerned with their partners' sexual habits and history than they are now."

And for many gay men and their health providers, that doesn't spell liberation—it spells trouble.