People not infected with HIV but at significant risk of becoming infected have a powerful weapon on their side – pre-exposure prophylaxis with a medication called Truvada. This is a combination medication (emtricitabine/tenofovir) when, if taken daily, can prevent the transmission of HIV by up to 92 percent.
As per the CDC's recommendation, this medication is meant for risky sexual practices or drug use (usually heroin) that requires a needle. This brings up a rather touchy subject. Should expensive AIDS drugs be provided to people who are actively engaging in behaviors that will likely get them re-infected?
When heroin addicts are in the throes of addiction, prompting their next fix, nothing else matters. Certainly, HIV prevention is not high on their list of priorities.
While there has been ongoing debate regarding whether it would be cost-effective to provide injection drug users (IVDU) with Truvada, I believe the answer is obvious: No. And it is also irresponsible, as I will explain.
In a recent study, published in the Annals of Internal Medicine, researchers looked into whether or not providing PrEP for IVDU would be a cost-effective approach for HIV prevention if drug adherence is maintained. The authors argue that by providing people with IVDU with PrEP, frequent screening with antiretroviral therapy (should they become infected) we could potentially avert 26,700 infections annually and reduce HIV infections by 14 percent. But this is contingent on patient compliance – taking drugs as directed. This is one of the problems with the PrEP strategy.
In a real-world setting, I can assure you that addicts are notoriously unreliable – especially with compliance. This is based on having spent considerable time interacting with them in inner-city settings. They are unlikely to adhere to their medication schedule, and even possibly less likely to get tested regularly.
Perhaps more important is that improper or irregular use of AIDS medications will accelerate the emergence of resistant strains of the virus. Indeed, there are already case reports of people with mutant viral strains resistant to Truvada.
With drug use by injection, the problem is compounded by the fact that individuals exposed to contaminated needles and syringes are also more likely to engage in unsafe sexual practices. Under these circumstances, significant resistance to Truvada is a given. It is just a matter of when.
Perhaps I am being short-sighted. It could be that, indeed, we may be able to prevent HIV in this vulnerable population of people. In no way am I undermining the struggle of those suffering from drug abuse or IVDU at that. When you’ve come face to face with someone attempting to inject heroin into a hand where the flesh is already necrosed, it becomes apparent how desperate these individuals are.
IVDU are more likely to die from causes other than HIV; for instance, overdoses from their addiction, or sepsis, or heart failure. So, does it make sense to dispense a rather expensive medicine to people who are unlikely to significantly benefit from it, but will also render the drug less effective?
Truvada is not a tic tac. It's a valuable drug, and one that has made a considerable impact on HIV prevention and treatment. Let’s not run the risk of creating an expensive public health policy that will only yield bad results down the road.