We Can End the HIV Epidemic, If We Want To

This article is part of a series of stories inspired by our latest documentary, Stopping HIV? The Truvada Revolution.

Last June, the New York Times published two op-eds on the same day: one by the founder of a porn company, and the other by the founder of an AIDS foundation.

The first, written by Peter Acworth, the chief executive of Kink.com, argued that, "We owe it to performers and other sex workers to move beyond old models of prevention and educate them about all the safeguards at their disposal—including PrEP… Morality and politics shouldn't cloud prevention, on-set or off." (Full disclosure: I work at Kink.com as the Director of Sexual Health and Advocacy.)

The second op-ed took the opposite position. Michael Weinstein, the controversial founder of the AIDS Healthcare Foundation, wrote that "PrEP has failed to protect the majority of men in every clinical trial (study). Relying on negative men to take this medication every day just doesn't happen most of the time. If you have multiple partners over a long period of time and you are not using condoms, there is a very high likelihood that you will turn HIV positive."

The question isn't whether or not we want to keep the public safe from HIV—both men clearly do. Instead, it's about determining a realistic and effective approach to protecting at-risk individuals from one of the most nefarious infections in recent history. Ignoring the science, Weinstein calls PrEP a "party drug," while Acworth, a porn exec, is both better informed and more aligned with national health standards.

If we ask the general public to imagine the owner of porn production company, many are likely to think of shady men with greasy hair, dripping in gold chains. They are unlikely to imagine individuals doggedly committed to sexual health initiatives and promoting safe sex for their performers.

But in reality, the adult film industry is a front-runner when it comes to sexual health. For ten years, the industry has operated self-regulated testing protocols that have prevented HIV infections on set. It is not a surprise that developments like PrEP are closely watched and quickly added to existing education materials.

In a recent public hearing of the California Standards Board for Occupational Safety and Health concerning proposed regulations for the adult film industry, scientists and public health experts came together to oppose the condom-only prevention focus promoted by the AIDS Healthcare Foundation.

One of those experts was Dr. Robert Grant, a senior investigator at the Gladstones Institute for Virology and Immunology, professor of medicine at UCSF, and chief medical officer for the San Francisco AIDS Foundation. Grant testified, that " pre-exposure prophylaxis (or PrEP) is proven to be safe and effective and was approved by the FDA in 2012. The protective benefit is estimated to be 99 percent among men and transgender women who have sex with men when PrEP is taken daily… Limiting prevention options to only one and removing personal control and confidentiality is antithetical to good medical practice and the public's health."

Bottom line: PrEP is an invaluable tool in working to end the HIV epidemic.

Since 1991, new HIV infections in men who have sex with men have been rising while all other analyzed populations at risk have seen a decline in new infections. Data presented by Dawn Smith of the US Centers for Disease Control and Prevention (CDC) at the 2013 Conference on Retroviruses and Opportunistic Infections (CROI) showed that the HIV incidence among men who said they used condoms all the time were 70 percent lower than men who did not use them at all.

Graph via CDC

While 70 percent may sound great, it isn't 99 percent. It isn't 100 percent. This is why we need more options to better suit the needs of people to actively engage them in prevention.

Pre-Exposure Prophylaxis (PrEP) prevents HIV infections in HIV negative people through a continuous daily regimen of Truvada. Truvada is an antiretroviral medication that consists of two active agents which block enzymes that HIV needs to replicate and in essence "infect" a person.

It's true that HIV is the only infection that PrEP prevents. Often people say, "Well, what about Gonorrhea, Chlamydia, Syphilis, and Hepatitis C?!" To which I'd reply, "Do you always use condoms during oral sex?"

When discussing other STIs, we need to understand how they are transmitted, how they can be prevented, and how severe an infection actually is. Regular testing is the mainstay of prevention when it comes to many STIs. In the adult film industry, performers get tested within 14 days of a possible shoot to rule out acute or untreated infections and therefore significantly reduce the risk of transmission. PrEP users are required to get tested every three months for all STIs.

Herpes, HPV, and oftentimes syphilis can be easily transmitted by skin-to-skin contact. A condom can have some preventative effect but won't guarantee a significant risk reduction. While herpes and HPV are incurable infections, a vaccine exists that protects against four strains of HPV that could cause cancer, and herpes is an infection that many of us have been living with for decades. Syphilis, in turn, is curable.

Gonorrhea, chlamydia, and trichomoniasis are curable and easily transmitted during oral sex. (Again, very few people use condoms during oral sex.) We have vaccines for Hepatitis A and B, and C is now curable as well.

But HIV is not curable. If undiscovered or left untreated, HIV will lead to AIDS. An infection with HIV means that a lifelong regimen of numerous anti-retroviral medications is required to render the virus undetectable (TasP), and best protect the health of a person living with it.

When we consider side effects as the primary concern for people nervous about taking PrEP, let's compare taking one pill once a day to prevent a lifelong infection with taking up to five or six medications everyday to treat an infection. HIV negative people adhering to the daily PrEP regimen as prescribed have shown little to no side effects. The two side effects that could be concerning are potential impacts on kidneys and bone density. Both of these effects are closely monitored by the patient's doctor and won't leave irreversible damage if PrEP is discontinued.

The last common argument of anti-PrEP advocates is the problem of adherence. As Dr. Bernard Branson, a former associate director in the CDC's division of HIV/AIDS prevention, testified, "All [prevention methods] require consistent adherence. No prevention method is completely foolproof." While PrEP and condoms both require adherence to work, PrEP is far more forgiving. Parts of the medication has a half-life of up to 167 hours. Condoms have a half-life of zero.

What we are left with is the question of whether we are willing to let adults be in charge of their own health. Women now have the choice of which contraception to use. It's time to encourage at-risk individuals to make the same kind of serious decisions about their own bodies.

We can end this epidemic if we really want to. We have all the tools we need.

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