Effective health care is based on science, data and sound policy, not stigma. And stigma, not science or sense, is at the heart of David Kaufman's December 21 NY Post article "Why New York's Plan to Push the HIV-Prevention Pill Could Backfire," which critiques the use of PrEP (pre-exposure prophylaxis)--a daily pill that HIV-negative individuals can take to protect against HIV transmission--as an HIV prevention tool. This is yet another inflammatory opinion piece that cherry-picks its facts in the interest of stirring up controversy, and in doing so, ultimately flies in the face of science and sound health policy.
Kaufman claims to be merely questioning PrEP's sudden prominence--particularly its inclusion as a pillar in Governor Cuomo's plan to end the AIDS epidemic in New York by the year 2020--not disputing the science about its effectiveness in preventing new HIV infections, a data pool of evidence that grows larger every day. However, Kaufman completely mischaracterizes the New York State awareness and education campaign around PrEP expansion, using alarmist, hyperbolic language to paint an inaccurate picture that is the latest in a long line of anti-PrEP scare tactics. He argues that PrEP "has seemingly supplanted condom use as the state's most important prevention method" and that "as Albany sees it, popping a pill--rather than rolling on a rubber--is the key to eliminating new HIV cases." To hear Kaufman describe it, one would think that Governor Cuomo and the NY State Department of Health were about to put PrEP into the water supply and stop distributing condoms altogether. That couldn't be further from the case.
Here are the facts that Kaufman himself concedes are indisputable, indeed even going so far as to include them in his own anti-PrEP article, perhaps in effort to make his flawed argument seem balanced:
- PrEP works, and works well, as an effective HIV prevention tool when taken daily as directed and monitored by a physician, which is a requirement for getting access to the medication to begin with.
- With no cure or vaccine for HIV coming anytime soon, all HIV prevention tools, including PrEP and condoms, need to have a role in fighting this epidemic.
- Studies have shown that side effects of PrEP have been minimal, and although long-term usage data do not yet exist, it's also true that PrEP can be used in the short term and then stopped based on individual needs and concerns.
- We have the tools we need to end the AIDS epidemic in New York State by 2020. As outlined in the 70-page NY State Ending the Epidemic Blueprint, that strategy includes utilizing every effective tool to prevent new HIV infections and keep those with HIV healthy. To reach the 2020 goal, the Blueprint offers 30 recommendations to stop AIDS deaths and bring HIV infections below epidemic levels in the state, as well as seven "Getting to Zero" strategies. In practical terms, that means the Blueprint includes everything from a push for comprehensive sex education and expanded access to HIV treatment to increased HIV testing to expansion of harm-reduction initiatives like syringe exchange to expanded housing and special services--and yes, it includes both condoms and PrEP as two effective prevention tools.
Here are some additional contextual facts that Kaufman conveniently omits from his critique:
Up until PrEP, the only effective HIV prevention tools we have had are abstinence and condoms.
New York State has hardly placed condoms by the wayside as a sexual health tool that can prevent HIV, other STIs, and pregnancy. Between the NYSCondom and NYC Condom programs, New York State distributes in excess of 40 million free male condoms per year. That HIV prevention strategy is not disappearing; it's being supplemented by another tool, just as the birth-control pill became another contraceptive tool to prevent pregnancy.
The data on condom usage is clear: We have been relying on a condoms-focused prevention strategy to fight HIV/AIDS for over 30 years, and while condoms are cheap and highly effective when people use them properly and consistently, that single tool alone has not been enough. Despite widespread promotion of and access to condoms, more than 1.2 million people are living with HIV nationwide, and the national rates of new HIV infections have remained relatively static for decades, hovering between 47,000 and 50,000 annually. By contrast, thanks to one of the most comprehensive and innovative HIV/AIDS health infrastructures in the world, New York State is leading the charge to end HIV and beating the national standards: The annual rate of new HIV infections in New York State is dropping annually, and the most recent data had the number of new infections statewide at 2,925 in 2013, a number that needs to decrease to fewer than 750 annually to effectively end the epidemic.
All medical data suggest that PrEP is under-promoted and underused, not the reverse. PrEP is being promoted widely now as another prevention tool in the HIV toolkit because simply put, it's a prescription drug that many people still don't know about. Consequently, usage has been low, especially considering its efficacy. Even in the medical community, many providers are either unaware of it or aren't knowledgeable enough about it to feel prepared to prescribe it. The numbers speak for themselves. According to a 2015 CDC survey, 1 in 3 primary care doctors and nurses had never heard of PrEP. Likewise, the most current CDC statistics estimate that only 21,000 people nationwide are taking PrEP--and that number represents less than 1% of the populations who could most benefit from it because they are at high risk for HIV infection. Even with a focused effort by New York State started in June 2014 to increase PrEP use, PrEP uptake in New York, while increasing dramatically in percentage terms during the past year, is still low in terms of actual numbers: According to New York State Medicaid data from July 2015, the number of New York State Medicaid beneficiaries receiving PrEP in 2014-2015 totals at 1,330 individuals.
PrEP is not about pill-popping and then calling it a day. PrEP expansion plans include not only educating providers and scaling up the prescribing of PrEP to patients who decide it's a good choice for them based on consultation with a physician, but also counseling patients who choose to take PrEP about adherence and requiring follow-up visits with the prescribing physician every three months to test for HIV as well as other STIs.
Kaufman questions the logic of prescribing the same medication for prevention purposes that is used as an HIV treatment, but his own grasp of the facts is muddled. PrEP does combine into one pill two HIV antiretroviral medications (tenofovir and emtricitabine) that are also used for HIV treatment. What Kaufman leaves out is that PrEP is only offered in one fixed dosage for HIV prevention, and effective HIV treatment regimens include more than just the medications in PrEP and also vary from individual to individual. In short, PrEP alone does not constitute HIV treatment. Also, anyone who has HIV will tell you that taking a drug to prevent HIV, one that you can go on and off of per your own changing needs, beats having HIV and managing it by taking HIV treatment drugs for a lifetime.
The new NYC Department of Health "Play Sure" ad campaign that Kaufman mentions positions PrEP and condoms explicitly as prevention tools, ideally used together. The tag line on every single version of those subway ads is "PrEP + Condoms," not "Tired of Condoms? Try PrEP." The ad campaign is also part of a broader NYC safe-sex initiative; in 2016, the NYC Department of Health will be distributing a free, portable safe-sex kit containing condoms, lubricant, and a section to hold pills, which the city hopes will be used by those at high risk to carry PrEP.
New York has always been a leader in the fight against HIV/AIDS, and we are now in a unique position to show the world that we remain a visionary leader in the global HIV response movement. Governor Cuomo's stalwart commitment to ending AIDS in New York by 2020 is both unprecedented and innovative in its embrace of what is proven to be effective. He is a genuine champion for change in the fight to end AIDS, and he is to be commended for recognizing the role of PrEP and providing real leadership to make New York the first jurisdiction in the world to bring this plague to an end.