By Benjamin RyanAs escolhas pessoais e a saúde pública podem achar um denominador comum na profilaxia pré-exposição? “O PrEP não é uma bala de prata.” Se você falar com uma longa lista de pesquisadores e defensores do HIV On the controversial Truvada HIV prevention pill, you will hear a handful of them spontaneously utter this sentence literally.
Providing the drug to HIV-negative people is not intended as a panacea that will set aside all other methods of prevention, a specialist points out. And only time will tell whether pre-exposure prophylaxis (PrEP) will really help to inhibit the HIV epidemic in the US, particularly among gay men.Achieving public health success depends on whether Truvada ends up in the medicine cabinets of a critical mass of people at high risk of contracting HIV, and whether they end up adhering well to the daily regimen. it has been more than two years since Truvada, a pill that includes the antiretrovirals tenofovir and emtricitabine, common in the treatment of HIV, was okay for use as a virus preventive. Streams of paint have been spilled over the past 12 months on the apparent warm uptake of PrEP. But recent evidence suggests that PrEP is finally starting to become popular with gay men and that a flourishing revolution may be upon us. What is already abundantly clear is that providing drugs to HIV-negative people with a drug that can be as much as 100 percent effective in preventing HIV can be a powerful transformation at the individual level. Of the dozens (almost all of them gay men) who shared their stories for this article under taking PrEP, many described a personal and sexual revival that caused a change in life how, for the first time, they discovered what it is to have sex without fear.
"The PrEP made me feel good about being gay," says Evan (one of which preferred to use only his first name), a sex professional full-time 22 years who lives in Washington, DC "Growing being gay is still very difficult. The first thing we learn about our sexuality is that some people do not like us, and that we probably contrairemos HIV. Taking PrEP allowed me to enter my sexuality and feel powerful. "PrEP, he adds, “prompted me to accept all gay men as potential friends, sex partners or life partners regardless of their HIV status.” Quentin Ergane, 38, who works as a home care provider for adults with mental illness in Seattle may be the perfect candidate for PrEP. Despite being very familiar with the alarmingly high rates of HIV among his African American male friends who have sex with other men (MSM); despite having seen his father, his favorite cousin and his best friend all die of causes related to AIDS; despite a paralyzing fear of becoming HIV positive; and though he knows condoms could help protect him, he's only used them indiscriminately since his domestic partnership ended in 2009. "Leaving a period of 10 years without using condoms and now that you are single have to go back to use them, I just did not have the feeling that I was approaching anyone," Ergane says, adding that the decrease in pleasure during sex is another factor, if less important, contributing to their contempt for the latex which is a common refrain among gay men.
“Nem sempre me ocorre no calor do momento colocar um condom”, ele diz. “E também, esta atitude é muito antinatural. As pessoas realmente interrompem sua intimidade, sua conexão, sua paixão, seu tudo, e então colocam um preservativo e esperam que as coisas voltem ao mesmo nível?”After starting with PrEP earlier this year, “I finally felt free,” he says. "For the first time since I was a boy, I know that my sexuality will not be the cause of my death." *** When gay men describe not using condoms despite their intentions to do so, they will generally use language suggesting that it was an accident largely out of his control: “It was a slip.” Some may even describe it as an extra-bodily mental state: “I realized that my compatibility with condom use had changed.” Critics can argue that this raises to a trick of homeland prestidigitator to deflect the justifiable guilt for failing to develop a rational process. However, as John Guigayoma, a 28-year-old boy from San Francisco, can attest, sex has a powerful ability to override such reasoning. Like Ergane, Guigayoma found that his sexual behavior was going against the HIV prevention practices he was teaching - and which, in his case, he was also teaching others. Despite working at a health education provider, he used condoms sporadically as he struggled with the shame and guilt of leading a sex life that was making him incredibly unhappy, confused and lost. "I felt that I couldn't trust myself and that there was something wrong with me," Guigayoma says. "It just added to all my own shame: I'm not doing what I should be doing." Sarit Golub, doctor, PhD, a psychologist at Hunter College in New York City who is studying the use of Truvada by gay men, says the greatest benefit of PrEP is that it “separates the act of HIV prevention from the act of potential encounter”, allowing the rational mind to run the show. "I can't trust myself to use a condom," Ergane says, "but I can trust myself to take this pill every day." "The PrEP helped me take control," says Guigayoma, which started with Truvada a year ago. Reducing your risk of HIV with drugs gave him the chance to take stock of your life and take better care of yourself holistically. Part of this process was to forgive to prefer sex without latex. "Perhaps there is nothing wrong with me," he explained. "Maybe this is just the way I want to live my sex life." Such sexual life includes an increased risk of sexually transmitted infections compared to those who are faithful to the condom. Activists of PrEP believe that those taking Truvada following the advice from the Center for Disease Control (CDC) and testing for STI at least twice a year will lead to early diagnosis and that subsequent treatment will counteract the absence of latex. However, such realistic attitudes towards condoms are causing deep concern and even anger among some in the gay community. "It is no surprise that people think I am irresponsible," says Guigayoma. "But it is more responsible to recognize the reality of our sex life and to offer people options that they can work with than to dictate a particular pre-prevention tactic." Okay to treat HIV since 2004, Truvada has a long history of supporting the notion that monitoring is generally safe and well tolerated, and that doctors can easily monitor any development of renal dysfunction or reduction in bone density - the two major side effects of long-term use. The issue of drug resistance can be uncertain, however. Research do iPrEx study showed that no one who contracted HIV during the study developed resistance to the drug. But most participants were tested for HIV monthly, as anyone who maintains the CDC's minimum requirements for PrEP will only receive quarterly HIV tests - giving the virus more time to mutate. Another concern is that PrEP may lead gay men to increase their risk-taking, a phenomenon known as risk compensation. The argument is usually framed as one or / or between Truvada and condoms - take the pill, drop the latex - although in reality overlap in use seems common. Such rigid and dualistic thoughts fit with the popular saying that "condoms have failed" with gay men - a defeatist claim that fails to recognize that without latex HIV rates would likely be catastrophically worse. Other elements typically overlooked in this debate are the many behavioral practices that gay men also use to reduce the risk of HIV, and which can factor in risk compensation, such as: "seroposicionamento", in which the HIV-positive partner is on position passive or below; "Serotriagem" in which men try to have sex with the same serostatus partners; favoring oral sex instead of anal sex; or by the partner who is over (active partner) remove the member before ejaculation. None of the PrEP studies showed any evidence of risk compensation. In fact, both in the placebo phase and in the open extension of iPrEx, volunteers, all of whom received risk-reduction counseling, tended to be less risky. But as the gay world begins to discover PrEP, a different story may begin to emerge. In a winter interview, Robert M. Grant, chief researcher, doctor and Master of Public Health, a university professor at the University of California, San Francisco, was firm in saying that Truvada does not lead to risk compensation. But when summer came he recognized that he was starting to hear anecdotes about the contrary. Those looking for such a story didn't have to go far to find the unofficial PrEP poster boy: Damon Jacobs, a Manhattan therapist who won the title by recounting his experiences with Truvada on dozens of media channels. Uncontrolled in his enthusiasm for this form of HIV prevention, he has had no remorse about switching from inconsistent condom use to an almost completely latex-free existence since PrEP began. This did not prove the scarcity of people sharing their own experiences with PrEP for this article who reported engaging in varying degrees and various types of risk compensation. Some took Truvada for the clear purpose of opening condoms. Quentin Ergane, for example, is now enjoying getting down more often during sex. However, both are having fewer sexual partners lately. Time will tell how common risk compensation will become. A crucial question is whether those who have taken greater risks will also take their medicines. A combination of widespread risk compensation and irregular adherence to PrEP could push HIV rates in the wrong direction. And if risk compensation among people taking Truvada influences similar behaviors in others, HIV rates could increase among non-PrEP users. *** “PrEP works if you take it,” according to researcher Robert Grant.
In fact, no one in the iPrEx study or in your open-contracted HIV while taking Truvada four or more days a week. But even if Truvada offer a type of protection "bulletproof" we do not know if it will reduce the 50, 000 new cases of HIV hell-bent on consist in the United States each year.The key to the success of PrEP spread tailored, according to Anthony Fauci, MD, director of the National Institute of Infectious and Allergic Diseases, is that the field of public health stop "to cheat saying HIV is a 'equal opportunity employer'. " Approximately two-thirds of HIV infections in the United States are transmitted through gay sex. In fact, the group of men who have sex with men (MSM, in English) is the only category of risk that recently did not change the scenario: while heterosexuals and injection drug users have seen rates fall in recent years, the rates among gay and bisexual men only increased, especially among young people. This does not mean that all gay men should start taking a blue pill every day. There is still a big risk spectrum within the community. Take into account the estimate that perhaps less than 2,5 percent of sexual encounters between men involve one partner ejaculating into the other's rectum - the act is by far the most likely to transmit the virus. Arguably the most effective way to increase the power of PrEP is to target HIV-negative men who are not using condoms consistently, and especially those who are underneath when the partner ejaculates inside them. (This demographic priority would exclude men in a monogamous relationship or with another HIV-negative man or with an HIV-positive man who has suppressed the virus and is on regular HIV care.) “My focus is not on helping the concerned to get access to PrEP, ”says Jim Pickett, director of advocacy for prevention at the AIDS Foundation in Chicago. With such a priority in mind, resultados July of the iPrEx open phase are encouraging: those at greater risk of contracting the virus were both more likely to follow PrEP and were more likely to adhere. However, overall adherence was dramatically lower among younger participants. Hopefully, the benefits of PrEP will extend to individuals taking Truvada. According to Demetre Daskalakis, doctor, Master of Public Health, new health care commissioner at the AIDS Prevention and Control Center at the New York City Office, “PrEP, if given to the right population at risk, is not really only HIV prevention, but specifically it is prevention of acute HIV. ”In fact, during the first six to twelve weeks of infection - a period known as the acute phase - viral loads soar, which makes HIV transmission much easier. During this phase, a person may feel perfectly fine and continue to engage in the type of high-risk sex that exposed you to the virus in the first place, thereby helping the virus to make its way through your "network of sexual contacts". So, ultimately, PrEP can operate as a wire cutter that breaks the chain. *** As for bringing PrEP to a critical mass, much has been done estimate from the manufacturer of Truvada, Gilead Sciences, who only about 2,300 people are taking PrEP. But this data has many limitations that are often overlooked: it only reflects data from September 2013; he was shot down from only 55 percent of American pharmacies; and he excludes the thousands who are taking PrEP through studies. Numerous healthcare providers who have been contacted for this article have reported that since the media buzz started in 2013, they have seen a 2, 5 or even 20-fold fluctuation in prescriptions. "We have seen a tremendous increase in interest," says C. Bradley Hare, physician, director of HIV prevention and care services at the Kaiser Permanente Medical Center in San Francisco, where 250 patients have been on PrEP, compared to 40 years ago. “It has grown and maintained over the past year.” Why would PrEP candidates choose not to take it? To begin with, there is the possibility of barriers to insurance (although in PrEP they are usually covered), concerns about side effects (founded or unfounded), an unwillingness to take a medicine every day, and fear of being stigmatized as a person promiscuous who has unprotected sex. But the biggest block for gay men could be their own lack of information that PrEP could personally benefit them. Daskalakis recently published a study with gay men at meeting points in New York City, who found that of the 80 percent who were potential candidates for Truvada, more than three-quarters did not think they were at sufficient risk to use PrEP. But perhaps the strongest case for PrEP is not necessarily made in the context of anonymous meetings. Research critically neglected suggest that gays are many more likely to use condoms in a chance encounter and that between one third and only above two-thirds Transmissions between men occur with their primary partners. In other words: a lot of guys are contracting HIV from boyfriends, not from sexual encounters. The transmission window appears to be generally open when there is a need to show confidence and experience intimacy in a new relationship, leaving the condom aside - before men have been tested for HIV and discussed monogamy. *** Unfortunately, an unpublished study led by New York University professor of psychology and public health, Perry Halkitis, PhD, Master of Public Health, found that young MSM in romantic relationships were less likely to see use in taking PrEP despite not using condoms. On the other side of the coin are recent discoveries from a published study recently co-authored by Kristi Gamarel, PhD at Brown University and Sarit Golub at Hunter College who studied adult MSM men in New York City - a group of older men, average age 32 - who were in stable relationships in which the two were HIV negative. When men cited intimacy as the reason they had sex without a condom with their partners, the likelihood that they would express interest in PrEP rose to 55 percent. Those who reported having sex without a condom with someone other than their partner were also more likely to say that they would use PrEP. As well as it must be taken into account that HIV affects black MSM more disproportionately: They make up about a fifth of all annual infections in the United States. Young black MSM are at particularly higher risk. An alarming 12 percent of young black MSM in Atlanta contract the virus each year. The key to engage this demographic population, said Phil Wilson, founder and CEO of the AIDS Institute in Negros, is to use targeted efforts for equal. "Someone shows up in sneakers or rap music or a T-shirt and is popular in the Bronx," says Wilson. “Four days later it's on the posters at Watts and Compton. So there are mechanisms in vogue that are used every single day to reach young black people. ”Unfortunately, trying to get Truvada usually means battling with primary care doctors who refuse to prescribe a prescription they are not familiar with, with which they they believe it will lead to risk compensation, and which they mistakenly consider highly complex to monitor security. Part of the problem stems from Gilead's decision not to announce Truvada as PrEP. Instead, the company makes modest donations to community groups, universities and public health agencies that take some time off in educating the public and doctors. This remains a stark contrast to the spread of birth control in the 60s, when GD Searle & Company sent an army of "minute men" to doctors' clinics to promote the Enovid contraceptive. "In some cases, because the gay sex be so stigmatized, it is leading doctors to make inappropriate judgments," says Jose Zuniga, PhD, Master of Public Health and president of the International Association for AIDS Care Providers. Until recently, the clinic Kaiser Permanente in San Diego called for those looking for PrEP sign a form that warned, "At any time, the Contractor may consider stopping the PrEP if there is continuing evidence of risky sex or is positive for DST's." No matter that both have sex without a condom as sexually transmitted diseases on the list of what makes someone a candidate for PrEP first. Lisa, a woman of 34 years living in a big city on the East Coast that are wanting to conceive of their HIV-positive boyfriend first asked her gynecologist about PrEP. “As soon as I told her that my partner was HIV positive, the look that woman gave me was so disgusting,” Lisa remembers. "She spoke to me as if I were an irresponsible person and the scum of the Earth." As is apparently highly common, Lisa's doctor told her to see an infectious disease doctor, who then told her not to look for HIV- negative and that she went to see her first doctor, subjecting her to months of coming and going as she looked for a doctor who sympathized with PrEP. "It was so humiliating," Lisa said. Daskalakis, in turn, fears that experiences like Lisa mean that medical specialists will become the large group who prescribe Truvada and that ordinary doctors will do tests to select potential candidates for PrEP. *** Data of promising efficacy aside, worrying findings emerged in the open phase iPrEx: participants took four or more pills a week just 33 percent of the time and adhered 12 percent of the time daily. Fortunately, it appears that MSM taking Truvada may miss up to TRE doses per week and probably remain completely protected. It is estimated that even taking the pill only twice a week reduces the risk of HIV by 76 percent. In this perspective, there is hope that the first findings of an ongoing study of the use of PrEP in the real world among MSM and trans women in San Francisco, Washington, DC, and Miami. One month into the study, participants were joining four or more times a week at rates of 92 percent, 90 percent, and 73 percent, in their respective cities. Daily adherence, however, was only 66 percent, 45 percent and 19 percent. And if this study follows trends in the iPrEx open phase, adherence rates may drop over time. Michael Weinstein, president of the AIDS Healthcare Foundation (AHF), media adviser on quotes opposing PrEP, insists, “There is no evidence in the scientific literature that PrEP is a successful approach to public health.” He points to the fact that low compliance has pushed down population-level effectiveness, and then he demonstrates average risk reduction data as failures. THE media campaign "Facts Prep" opposes PrEP as a public health intervention for these reasons. But another way to look at a median 44 percent effectiveness is to say that if you give PrEP to a good number of high-risk gay men, HIV rates will decrease. These data are also close to the reduction about 60 percent in woman's risk of transmission to man that male circumcision confers. Research is beginning to show that the massive campaign to circumcise African men are not only connected to reduce HIV among circumcised men, but also among women. Which brings us back to Daskalakis' point that PrEP can effectively prevent people from transmitting HIV to others by keeping people who are having high-risk sex from contracting HIV in the first place. Weinstein's ultimate argument is that the dominant prevention approach should focus on promoting condom use along with the treatment and diagnosis of HIV-positive people, and that PrEP should be reserved for “special cases.” In fact, Recent research suggest that having a viral load undetectable makes it practically impossible for people living with HIV to transmit HIV. But low adherence to antiretrovirals also pushes down the effectiveness of the population level of “treatment as prevention” (TasP): One estimated 75 percent of Americans treated for HIV actually have a completely suppressed virus. Another way to look at this is that only 40 percent of all Americans diagnosed with HIV are on treatment and only 30 percent are virally suppressed. Admittedly, giving medicines to people with HIV is a much more objective way to contain transmissions than giving Truvada to HIV-negative people in the hope of preventing any HIV they may encounter. But all these things considered, PrEP is still being maintained at a much higher standard: adherence is always factored into the debate about its merit while that element is largely ignored when discussing TasP. Furthermore, only a minority of MSM apparently consistently adheres to the condom. “There is not a single person I know who thinks PrEP is perfect or that adherence is a critical issue,” says Mitchell Warren, executive director of the global HIV prevention support group (AVAC), who added that adherence is critical for all forms of HIV risk reduction. "If there was a perfect intervention, we would prefer it," he says. “But in 2014, the best approach is a Patchwork approaches good, but not perfect. Why would we want to give up any of them does not make sense to me. " By the Numbers Considering the effectiveness Prep 44 percent In the experiment iPrEx with MSM and transgender women who were the first to demonstrate the effectiveness of Prep 2010, the group given Truvada had a reduction of infection by HIV 44 percent rate compared with the placebo group. 92 percent Only 51 percent of participants assigned to take Truvada in iPrEx detected the drug in their systems, but they had a reduction of HIV 92 percent rate compared with those with no detectable drug. The American Center for Disease Control and Prevention (CDC) incorrectly the consistent use of Truvada reduced the risk of HIV in "to 92 percent." The data is not the upper limit of risk reduction of Truvada with perfect grip; it represents a risk reduction of average among those taking absolutely no drug. 99 percent A specific modeling (Called regression analysis) based on the data iPrEx designed to take Truvada seven days a week reduces the risk of HIV 99 percent. The real data, researchers estimate could be between 96 percent and greater than 99 percent. 100 percent Na placebo free phase iPrEx researchers analyzed the data with what is called stratified analysis, which allowed the evaluation of them reflect more directly the fact that, as early in the iPrEx, nobody contracted HIV while taking Truvada four or more days a week: they designed to adhere to the regime that offers favorably 100 percent efficacy. A drawback of using this different way of statistical analysis was a range of broader estimates: they could only speculate with confidence that the efficacy was nothing less than 86 percent.