Doctor with Blood Samples

Bioethics Forum Essay

Truvada: No Substitute for Responsible Sex

A new debate is surging through the gay male population in the United States: should gay men take a drug that can reduce their risk of contracting HIV? The drug in question is Truvada, a combination antiretroviral commonly used to treat HIV infection. In 2012, Truvada was approved by the U.S. Food and Drug Administration as the first drug to be used for pre-exposure prophylaxis in the longstanding battle against HIV.

The availability of Truvada as a prevention tool has led to some positing that it could be the “new condom” for gay men, while others have voiced concern that the drug will be used improperly or will only exacerbate rising rates of unsafe sex among gay men. But what is currently missing is a frank discussion about personal responsibility in gay men’s sexual health choices, and the duties all of us have, not only to ourselves, but also to our partners and the gay community as a whole.

There is no doubt that Truvada has demonstrated its potential for success. In a clinical trial examining the drug’s effectiveness in transgender women and men who have sex with men, researchers found that Truvada, on average, was effective in reducing HIV transmission by 44 percent. For those study participants who adhered to the daily regimen of the drug and had detectable levels of the medication in their blood, the protective effect of high adherence was over 90 percent. Whether the participant was on a placebo or the study drug, treatment was provided with a comprehensive package of prevention services, including monthly HIV testing, risk-reduction counseling, condoms, and the diagnosis and treatment of other sexually transmitted diseases.

There are drawbacks to Truvada. Rare side effects can occur, and there exists the real possibility that, without rigorous testing, a person who is unknowingly HIV-positive and fails to follow the daily drug regimen could develop a resistant strain of HIV. Regardless, for those populations within the gay community in which the HIV/AIDS epidemic has reached crushing levels and for men in serodiscordant relationships (in which one man is HIV-positive and one is HIV-negative) who are looking to alleviate the worry of HIV transmission, Truvada offers real hope.

The debate about Truvada has not necessarily focused on those who need the drug, however. Instead, it has centered on those who want the drug, specifically, those who want to use Truvada because their condom use is sporadic or simply because they refuse to use condoms at all. For younger men, infrequent condom use may stem from the realization that HIV is no longer the lethal attacker it once was. Whatever the justification is for ditching safer sex practices, the recent evidence of this unhealthy activity is startling and cause for concern, particularly in light of how many men continue to be unaware of their HIV status.

But should the gay community accept this increase in high-risk sexual behavior now that there is prevention in a pill? No. Mark Joseph Stern, a contributor to Slate, has argued that “[e]very gay man with multiple sex partners should take Truvada” and that fears that gay men will irresponsibly use this medication are “condescending and incorrect” and evidence of “paranoia.” Stern’s argument is flawed.

If some gay men have made the decision to not use condoms because they no longer fear exposure to HIV, there is valid concern that this “condom use nonchalance” within the gay community will apply to Truvada use as well. If some gay men view HIV as a chronic and manageable illness with few consequences and therefore decide that the enjoyment of unprotected anal sex is worth the gamble, why is there any reason to believe that they will take a drug every day and get tested regularly for HIV and other sexually transmitted diseases? In the studies that have been conducted on Truvada, research participants have not increased their sexual risk behavior while using the drug. Yet findings in the confines of clinical trials cannot be reliably extrapolated and applied to the real world, where constant reminders about sexual health and diligent drug adherence are absent.

Personal responsibility for one’s actions has simply been thrown out the window in a community in which we are too often concerned about stigma and moral judgment. We dare not speak against the reckless behavior of others because we wring our hands over the omnipresent worry that we will shame one another with “should.” Stigma has a place in public health, though. Not the denigration of persons or communities, but the judgment of irresponsible actions. We stigmatize smoking cigarettes, drinking and driving, and any number of deleterious behaviors because they affect not only the individual — they have ramifications for the broader public.

Wearing a condom is as simple a protective measure as abstaining from alcohol while driving, wearing a seat belt, or choosing to get a flu shot. Sex without a condom outside of monogamous relationships is a high-risk activity for all men and women, regardless of sexual orientation. Simply choosing to go without protection because of the physical gratification it may bestow calls for a degree of condemnation, not just a prescription.

In law and ethics we regularly talk of duties — the duties we have to one another and the duties we have to the broader society. That sense of duty is being lost in a debate where too many are rushing to Truvada for an easy out that does not exist and where others are tiptoeing around dangerous actions that can hurt those we know and love. Condoms are not 100 percent effective. Nor is Truvada. It is a mistake to assume that gay men will be any more diligent about taking Truvada daily than they are about using condoms regularly.] Gay men must return to taking seriously their own and others’ decisions about sexual responsibility.

This is not only for themselves and their immediate experiences but also for their partners and for their partners’ partners. Too many men have simply come to believe that their individual choices do not reverberate outside the confines of their intimate encounters, and this is a fallacy. And Truvada, and every other form of HIV prevention, present or future, will not correct for that.

Richard M. Weinmeyer, JD, MPhil is a senior research associate with the American Medical Association’s Ethics Group. The viewpoints expressed in this article are those of the author and do not reflect the views or policies of the American Medical Association.


Posted by Susan Gilbert at 02/14/2014 01:58:11 PM |

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