Does Treatment As Prevention Work?

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NZAF Executive Director Shaun Robinson has an exclusive chat with express about a disturbing new trend.

Can you tell us a bit about the notion of ‘treatment as prevention’ and the ramifications of it are for safe sex in New Zealand?

Treatment as prevention is the idea that people taking HIV treatment medications have such a low level of the virus in their blood that they can’t pass it on.

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The big danger is that it does not work to prevent the spread of HIV in the gay community and if people give up condoms thinking it will, HIV will get worse.

NZAF has always promoted both condoms and increased access to medications. It is good news that taking HIV medications regularly will reduce a person’s infectiousness.  It’s good for the person’s health and it helps with prevention; but as a senior HIV Doctor in Auckland recently said “we will never treat our way to ending HIV”.

The biggest problem with using undetectable viral load as a prevention approach is that it may encourage gay and bisexual men to think that all men living with HIV are no-longer infectious and, therefore, condom use is no longer necessary.

If people stop using condoms, the result will be an increase in infections. We are seeing this happen in Australia and other countries even though they have high levels of HIV treatment coverage of gay and bisexual men.

An individual must know they have HIV to be treated and studies tell us that 1 in 5 gay men in Auckland who have HIV don’t know they have it.

Research tells us that HIV is not primarily passed on by people who know they’ve got it – it’s mainly passed on by people who don’t know their HIV status. Further studies show that approximately half of all HIV transmission occurs within the three month ‘window period’ when a person is highly infectious and before HIV can be easily detected in a test.

Treatment as prevention cannot work for this group and, therefore, cannot stop this large part of the epidemic.

Relying on undetectable viral load puts most of the responsibility for HIV prevention on people living with HIV. This undermines the community spirit that has been built up over 30 years where all gay and bisexual men both living with and without HIV take responsibility to protect each other from HIV by using condoms.

Condoms share the responsibility equally between those who want to protect themselves from getting HIV and those who want to prevent themselves from passing it on.

If a person living with HIV either has a lapse in regular use of their HIV medication or contracts an STI, this can cause a significant rise in HIV viral load and increase the chance of passing HIV on through unprotected anal or vaginal sex.

What has kept NZ very safe for 30 years is the use of condoms by all men having sex with men. HIV Positive or Negative, which is the deal for everyone, every time.

Trying to pick who is infectious and who isn’t is a lottery not a strategy, and in Australia, where they are trying it, HIV for gay men is skyrocketing.

Can you tell us a bit about Prep and Pep and what they do to the body?

Prep and Pep are the use of HIV medications before being exposed to the virus, say through sex (Prep) or after some risky incident (Pep).

The idea is that the medications reduce the chance of a person getting HIV despite them being exposed to it. In New Zealand Pep is provided by doctors if there has been an accident such as a broken condom. Prep, medication before a risk, is not funded in New Zealand.

What are the side effects involved with taking this drug?

All HIV medications have side effects, depending to a large extent on the individual, although the modern drugs are getting better and better. Side effects can include, feeling nauseous, diarrhoea, dizziness, depression, sleep problems, itchy skin. Its not very appealing, and in fact in American studies where they have tried to use Prep for prevention they have had real problems getting guys to take it because of the side effects.

It’s more expensive than using condoms and potentially damaging for the body, why has this become a trend overseas?

If you have sex once a day for a year it will cost less than $100 a year for condoms, whereas Prep costs about $10,000 to $15,000.

It’s not only expensive but it’s kind of silly, Prep is asking guys to take a pill every day so that they won’t have to take a pill every day.

So yes, good question why are other countries supporting it? There are four reasons I think.

  • In some countries they really don’t know what to do to stop HIV amongst gay and bisexual men. They have failed to get condom use anywhere near as high as it is in New Zealand and they think men can’t be convinced to use condoms.
  • Some very vocal men in the gay and HIV scenes overseas really resist condom use and have been pushing for alternatives.
  • Of course drug companies will make huge amounts of money if they can convince people who are well to take drugs designed for people who have a chronic illness.
  • Anal sex is 18 time more risky than vaginal sex for HIV. Because of this drug based approaches to prevention have more chance of working for heterosexuals. Many countries have become interested in treatment as prevention from a heterosexual view point, but the risks for gay men are very different.

How do we prevent this trend from becoming popular in NZ?

The gay and bisexual community needs to hang together on this. New Zealand has a very strong condom culture for gay and bisexual men. It has kept HIV at very low levels.

Condom use is a community-wide deal or a contract; positive and negative men have been using condoms and that allows everyone, the whole community, to have as much sex as they choose and still stay safe.  If you do have unprotected sex in Auckland you are way safer than if you have it in Sydney for example, because our condom use has kept the level of HIV much lower over here.

Anyone who starts saying that they are different, or they are non-infectious or they are not part of the community deal is putting everyone at risk. So its simple don’t mess with success, don’t break the deal, Love Your Condom.

 Article | Oliver Hall

For further comment or to arrange an interview please contact:  

Shriya Bhagwat-Chitale
Senior Communications Officer
New Zealand AIDS Foundation | Te Tūāpapa Mate Āraikore o Aotearoa
p  | +64 9 300 6963 m | +64 21 741 604 e  |shriya.chitale@nzaf.org.nz

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