Anthony Fauci and Hilary Marston of the National Institute for Allergy and Infectious Diseases shared the good news that antiretroviral drugs can not just treat HIV effectively, but can even prevent it. “The science has spoken,” they said in an article in the New England Journal of Medicine. “There can now be no excuse for inaction.”
What excuses are we talking about here? There has been controversy over the antiretroviral treatments. These drugs must be taken regularly throughout the patient’s life, and they don’t work if they’re not taken correctly — which could lead to resistance, as it has with antibiotics. The drugs cost some $13,000 a year, an amount that worries people who fear that the quest to make these drugs more widely available will make other drugs less available. They have side effects which some have called “worse than the virus.”
But the biggest controversy centers on the fact that these drugs reduce the risk of spreading AIDS through risky sexual behavior. An infected individual using the drug correctly is less likely to pass the disease along to unprotected partners, and a healthy person using the drug correctly is less likely to contract the disease from unprotected sex. Some experts — and plenty of commentators — worry that having the option of taking a daily drug to prevent AIDS will lead people at high risk of developing the disease to behave recklessly.
We see this with other drugs designed to help people control diseases that would otherwise require lifestyle changes. Patients sometimes feel like their cholesterol medications give them permission to eat those cheeseburgers or that high blood pressure medication absolves them of having to change their work habits.
But the controversy over antiretroviral drugs goes deeper. For one thing, a person using these drugs can still infect another person, though the risk is lessened. Some public health experts also worry that thinking of prophylactic use of these drugs as an alternative to the use of a condom could mean an upswing in other sexually transmitted diseases, since retrovirus drugs don’t protect against STDs in general, but only against AIDS.
AIDS Healthcare Foundation President Michael Weinstein has called Truvada, an antiretroviral drug that has been in use for a decade, “a party drug.” Some users report feeling “shamed” for their decision to take the drug. And some physicians may be uncomfortable with the drug for exactly the same reasons some doctors were uncomfortable with birth control pills a couple of generations ago: both categories of drugs can be perceived as an aid to promiscuity, something that lets people have irresponsible sex without facing the consequences.
The public health controversy may continue, but individual doctors making decisions about the treatment of individual patients — for HIV or any other condition — must think about what’s best for the individuals we’re treating. Their needs, thoughts, feelings, and beliefs must come first.
