Getting PrEP schooled

[Elok]

So, I read this Atlantic article a few weeks ago.  Basically, there exist a set of Pre-Exposure Prophylactics, commonly known as PrEP: drugs which, when taken regularly, can prevent the taker from acquiring HIV with almost perfect reliability.  As in, 99.95% effective, or something similar.  Now, these drugs do not prevent the transmission of any other disease, nor pregnancy.  They also, at this point, cost somewhere north of a thousand dollars for a month's worth of doses, and not all insurance covers them.

The Atlantic article argues that this is outrageous, since most homosexual men do not use condoms, and receptive gay men are not in a position to easily demand that their partners put one on.  Since AIDS is the only truly horrifying STD, PrEP is thus analogous to the Pill for "bottom" guys: a form of long-overdue liberation.

My response to the article was moral revulsion.  To take PrEP while scorning condoms is to use a vastly more expensive, generally less effective option--you can take PrEP faithfully and still catch (and spread!) herpes, hepatitis, gonorrhea, syphilis, etc.  Covering PrEP, at least for the kind of usage the author was endorsing, would entail the allocation of scarce healthcare resources that could be spent much more wisely than on subsidizing an irresponsible lifestyle choice.  For example, twelve grand a year would give free doctor's checkup visits to maybe ten low-income families.  Or a massive number of actual vaccinations.  You could at least take a good bite out of the cost of some poor guy's chemo.  And so on.  Yes, condoms make it less fun.  I use 'em anyway, and I don't see why this guy can't.

On the other hand, I'm not really a sympathetic audience for pieces like this; I'm a married, religious, straight man who has never had the slightest interest in promiscuity.  What do people without my biases think?

[Lorizael]

(I haven't read the article, so I'm guessing as to whether this post is relevant.)

When I worked for the FDA, I was part of the rubber stamp that gave drug companies approval to send PrEP drugs (such as Truvada and a couple others I can't remember) to African countries under the PEPFAR program. As I understand it, the idea behind these drugs is that AIDS is an extremely awful problem and some people cannot be convinced to use condoms, so let's give them these drugs instead.

[Unorthodox]

On the other hand, I'm not really a sympathetic audience for pieces like this; I'm a married, religious, straight man who has never had the slightest interest in promiscuity.  What do people without my biases think?

I'm afraid I hold the same bias as you in this particular area, but pride myself on being willing to argue any side of any topic, and tend to keep open minds to all sides as a result. 

My response to the article was moral revulsion.  To take PrEP while scorning condoms is to use a vastly more expensive, generally less effective option--you can take PrEP faithfully and still catch (and spread!) herpes, hepatitis, gonorrhea, syphilis, etc.

First off, your first mistake (and the one the article makes too) is to apply morals to the question of insurance.  Insurance is NOT a moral dilemma, at least here in the States.  It's a financial one.  Second, the same argument can be made over birth controls, yet they tend to be covered by insurance.  In fact, many have a moral revulsion to birth control, including condoms. 

Covering PrEP, at least for the kind of usage the author was endorsing, would entail the allocation of scarce healthcare resources that could be spent much more wisely than on subsidizing an irresponsible lifestyle choice.  For example, twelve grand a year would give free doctor's checkup visits to maybe ten low-income families.  Or a massive number of actual vaccinations.  You could at least take a good bite out of the cost of some poor guy's chemo.  And so on.  Yes, condoms make it less fun.  I use 'em anyway, and I don't see why this guy can't.

Insurance is a game of finances.  There is an argument to be made that choosing to cover a person by giving them PrEP is a whole lot cheaper than covering this same person after they get HIV (unless I missed rule changes, the insurance can't drop you because you get HIV).  Clearly according to the same article you link, some insurances have made that decision. 

[Rusty Edge]

I think it's cool that they can make such a drug. I like to see breakthroughs.

My background bias is much the same as yours. Well, I do have a distinction. I think promiscuity is really interesting to hear and read about, it's just not for me because I get emotionally involved. Maybe like somebody who likes to watch skydivers and extreme sports, but doesn't want to do it.

I know it's not for me, but I don't have an issue with others doing it.

I do object to people getting others sick due to recklessness, negligence and lack of disclosure.


Having worked for an insurance company, I would have to agree with Uno. They do what they do for financial and statistical reasons. They live by margins. Whatever they do, it isn't personal.
It's easy to get insulted by the rules and rates, but it's not personal. They are responding to fraud and risk. If they're wrong, it'll cost them.

[Elok]

I can see your POV there; I suppose I was responding more to the article author's moralizing tone--not that it's in insurance companies' best interests to cover PrEP, but that it's morally wrong for them not to.

[Rusty Edge]

I can see your POV there; I suppose I was responding more to the article author's moralizing tone--not that it's in insurance companies' best interests to cover PrEP, but that it's morally wrong for them not to.

The author isn't exactly being fair to insurance companies, either. I wonder how he would feel about rates that charged single gay men an extra $1000/ month vs. married ones? Sort of like smokers vs. non/smokers. There wouldn't be any entry level jobs available for them because of the substantial cost to employers. Or what would happen if they approached the question like pitbulls, and refused to insure a risky lifestyle choice at all, or only as high risk insurance?

I suppose that the likely answer to my hypothetical question is that the government will try to further regulate the insurance companies, rather than embrace it as a market -based solution to high risk behavior. The predictable result of that is that some companies would get out of that branch of the business, reducing competition, and causing costs to rise.


Maybe the real answer is a mutual insurance company for gay men. Farmers, firemen, lumbermen, etc. have formed mutual insurance associations in the past when they thought they would do better independently, or couldn't get coverage.

[Buster's Uncle]

Man Gets Rare Strain of HIV Despite Taking Antiviral Pills
LiveScience.com
By Laura Geggel  March 2, 2016 11:17 AM



In the first documented case of its kind, a man taking an effective antiviral medication still contracted a drug-resistant strain of human immunodeficiency virus (HIV), a new report finds.

The 43-year-old man in Canada was taking Truvada, the medication approved by the Food and Drug Administration (FDA) to reduce HIV risk among HIV-negative people, according to the FDA.

The case suggests that people taking Truvada can still get HIV if they're exposed to a strain of the virus that is resistant to the two antiviral medications contained in the pills — tenofovir and emtricitabine, the researchers said.

The man had been taking Truvada daily for the past two years. Normally, HIV-negative people who are at high risk of contracting HIV, including those who have sex with HIV-positive partners, take Truvada on a daily basis to lower their chances of getting the virus, according to the FDA.

The man, who reported that he has sex with men, got tested for HIV, according to the report. The test showed that he was HIV-positive, the researchers said, according to the February report, presented at the 2016 Conference on Retroviruses and Opportunistic Infections (CROI) in Boston in February.

A genetic analysis of the viral strain the man was infected with showed that he had likely acquired it recently, and from a single source, the report found. Moreover, tests showed that it was multidrug-resistant.

The case is concerning, but likely rare, experts told Poz, a news outlet that covers HIV and AIDS.

"I certainly don't think that this is a situation which calls for panic," report co-researcher Richard Harrigan, the director of the lab program at the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, Canada, told Poz. "It is an example that demonstrates that [pre-exposure antiviral medication] can sometimes be ineffective in the face of drug-resistant virus, in the same way that treatment itself can sometimes be ineffective in the face of drug-resistant virus."

According to the Centers for Disease Control and Prevention (CDC), Truvada can reduce by 92 percent the risk of HIV infection in people who are at high risk of contracting the virus. The drug is more effective when it is taken consistently and used with other HIV-prevention methods, such as condoms.

Two large clinical trials of Truvada show that it lowered people's HIV risk substantially, according to the FDA. In one trial, of about 2,500 HIV-negative gay and bisexual men and transgender women, Truvada lowered HIV risk by 42 percent. In another study of 4,800 heterosexual couples in which only one was HIV-positive, it reduced the risk of HIV infection in the HIV-negative partner by 75 percent.

Although the man's HIV strain is resistant to multiple drugs, doctors have still found a way to treat him. The man is on a regimen of other drugs, including dolutegravir (brand name Tivicay), darunavir/cobicistat (Prezcobix) and rilpivirine (Edurant), and has "a fully suppressed viral load," according to Poz.

http://news.yahoo.com/man-gets-rare-strain-hiv-despite-taking-antiviral-161714982.html