Although antiretroviral drugs have been used and are being used to treat people who are already infected with HIV, in some cases they have also been used to help a person’s immune system prevent the HIV virus from being established in their body in cases such as rape as post-exposure prophylaxis (PEP).
This fairly new school of thought in which any person can take an ARV pill daily if they anticipate risky sexual behaviour that may make them vulnerable to HIV infection raises very critical issues,
“Why give an ARV pill daily or in whatever doses to reduce HIV infections while other models of prevention have been proven to work?” poses Dr John Ong’ech, a gynaecologist and HIV specialist in Nairobi. He adds: “We have the ABC (Abstain, Be faithful and or use a Condom) and Prevention of Mother to Child (PMTCT) among others.”
Ong’ech says: “This would be sending the wrong message while a lot of money is being pumped into behavioural change messages which have been significant in HIV prevention.”
This information comes from a statement by the Swiss Federal Commission for HIV/AIDS, based on a report which revealed that a HIV positive person who is taking effective antiretroviral therapy has an undetectable viral load and has, therefore, a very low risk of infecting others that the concept of PrEP as a preventive measure was derived.
Since the significant percentage of HIV transmission worldwide is through unprotected vaginal sex, it was believed that an ARV pill taken daily could not only significantly reduce the chances of infection, but it could possibly eliminate the risk of HIV transmission altogether.
A statement that has clearly gained support in certain circles and has inspired PrEP studies in both mice and monkeys.
The positive results in these animal studies, for it was indeed proven that PrEP can be effective against HIV infection based on the animals used, has provoked urgent calls for more solid and conclusive PrEP studies.
This is in spite of the potential damage not only for ARV drugs abuse but also damage to the immune system posed by such a strategy.
“The complexity of HIV infection demand radical ways to fight further transmissions. The bottom line is that people need protection,” explains Pauline Irungu, East Africa’s coordinator for the Global Campaign for Microbicides. “While ABC has worked for some people, it has not offered protection to others and, therefore, the HIV epidemic continues,” she explains. Irungu adds: “New tools are, therefore, needed especially those that women can initiate since they bear the brunt of the epidemic. PrEP is one such potential tool and research is yet to be completed.”
The anti-retroviral drugs being tested for Prep are Truvada (or a combination of Tenofovir and emtricitabine) or Tenofovir alone.
These drugs have been selected on the principle that taken once a day, they not only have limited side-effects but they also show a slow development to drug resistance particularly if the person taking them got infected with the HIV virus.
“The concept has been inspired by models of prevention along the lines of PMTCT and greatly informed by contraceptive mode of prevention (for family planning) but it is dangerous to say that anyone can take these drugs as a preventive measure,” emphasises Ong’ech, adding, “In discordant couples it is a workable strategy but under very strict medical scrutiny.”
The doctor believes that for discordant couples it can be significant during the period that a couple intends to get pregnant although it would still demand keen medical observation.
This, he says, is based on what he has observed in practice and as has been revealed by global studies that within one year, one in ten discordant couples will convert and both partners will test positive because of risky sexual behaviour.
Medical experts opposed to the strategy argue that Kenya, which is currently under study for PREP, does not have the systems required to support such a venture because a person cannot be put on ARV without having been tested for HIV.
In addition, once testing has been done and a supply of drugs given, another test needs to be done for the next supply. It, therefore, begs the question of how this can be practical in a system whose human resource and equipments such test kits are already strained.
The aspect of side effects cannot be over-emphasised. Health experts say that in some cases, side effects can be very severe causing hepatitis and kidney failure among other health complications.
“I am disturbed because as a social worker, I see HIV positive patients struggling to stay on medication despite the side effects,” explains Mary Atieno, from Kibera. “Research shows that some of the side effects can be so severe that one in five people will give up PEP treatment before completion.”
Further, the argument against PREP maintains that it is disturbing to expose HIV negative people to HIV drugs because the medication remains in the bloodstream for a long time. This may lead to toxicity and drug resistance if, unfortunately, the person gets infected with the HIV virus at some point.
More importantly, this mode of prevention does not factor in scenarios where people may have been recently infected with the virus but tested negative since they were still in the window period and the virus was undetectable.
“Every drug you take has side effects, this PREP isn’t a vaccine, to deliberately and with no strong reasons, expose yourself to HIV infection just because you swallowed a pill is unacceptable,” emphasises Dr Mary Amuyunzu, an anthropologist in Nairobi.
“There isn’t any strong reasons because other basic measures against HIV such as using a condom have been proven effective,” she says, wondering why scientists would propose that people go into a PREP mode.
Amuyunzu says PREP is a concept that basically complicates all preventive methods that have been pushed for before and proven to, if correctly followed, significantly reduce HIV infections.
“We are not talking microbicides which are a great option as we wait for a vaccine against HIV, but a drug whose long term potential to damage the immune system of an HIV negative person is very real.”
Her sentiments are echoed by Judy Kamau, an administrator in Nairobi who applauds the thought of taking a pill as is the case with some contraceptives as a preventive measure. However, Kamau is adamant that if the pill is an ARV for a HIV negative person then it is should not be used in such a manner.
“Well, if swallowing a pill can be a preventive measure then fine, since it has worked in preventing pregnancies, but ARVs are drugs with the side effects already observed on people living with HIV.”
Kamau adds: “It is actually complicating the basics drummed into the public of simple and effective ways to stay protected from HIV such as the famous ABC methods.” She adds: “Post exposure drugs (PEP) are understandable because they are used in situations of distress but not PREP for just anyone.”
Although there are already strong arguments against the issue of PREP as a preventive strategy, because put on the cost-benefit scale it appears to fare poorly, it has nonetheless not deterred scientists from exploring the idea further. As of December 2008, Kenya, Uganda, Tanzania, Malawi and South Africa were among those on the planned PREP trials.
As the debate for and against PREP rages on, only time will tell whether in indeed the gains far out weigh the losses, and whether putting HIV negative people on ARVs is the solution we need.
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