Ask the Doc: Gov. Cuomo Endorses PrEP for HIV Prevention
On this week's Ask the Doc column, resident HIV expert Dr. Howard Scheiner addresses news by New York State Governor Andrew Cuomo that PrEP using Truvada should be used to prevent HIV infections in those individuals who are HIV-negative, but at risk for infection.
Then, the doc tackles the sad situation of a Mississippi infant thought to be cured of HIV, but later discovered to be positive via virus hiding in reservoirs. So far, the only person known to be 'cured' of HIV is Berlin patient Timothy Ray Brown, who got rid of his HIV while undergoing an intensive bone-marrow transplant operation.
Q: Dear Doc, I was at a dinner on Fire Island when someone called one of the dinner guests stupid for taking PrEP. I just read in the New York Times that Governor Andrew Cuomo has endorsed the use of Truvada as PrEP to halt the spread of HIV. So, who's stupid?
A. That's an easy question to answer. No one is stupid. In 2012, there were 2.3 million new cases of HIV worldwide. In New York City last year there were about 3000 new cases. In order to try and cut the number of new HIV infections to 750 by 2020, the Governor has advocated putting more HIV negative people on Truvada.
There has been only a minimal decline of HIV transmission from 2007 to 2012 when it comes to men who have sex with men. As they say, "You can't offer condoms to people who don't want them." So, from a public health standpoint (not to mention the politics) this is a viable approach.
For my patient who last week told me that PrEP was a fallback position to his underlying desire just to turn HIV positive and finally be done with the constant worry about transmission, it clearly is an important tool in preventing HIV acquisition.
For another patient who wanted to start it because most of his friends in his Fire Island share were doing it, the motivation was more nuanced. It was peer pressure so he might start down a sexual road that he really wasn't sure he wanted.
As with the next question about change, the durability of long-term benefits with Truvada as PrEP won't be in for a while. For the individual, short-term side effects may negate its possible use and long-term side effects have yet to unfold in this setting. And of course, there is always the possibility of some unseen complications that can change the entire approach.
So, for the individual deciding on PrEP, I advocate speaking with your physician for perspective as well as listening to Mr. Cuomo and your Fire Island housemates.
HIV Resurfaces in Baby 'Cured' of HIV
Q: I just read in the New York Times that the "Mississippi Baby" who was "cured" of HIV actually still has it. Why did this change?
A. Everything in life and medicine is subject to change. That is why it is so important when getting medical information that it comes with a physician's perspective to lend an appropriate measure of validity to the news of the day. There is a bit of wisdom that comes with experience in medicine as well as life.
The answer was that the baby was never really cured. The apparent cure simply reflected the inability to find and measure whatever miniscule virus remained hiding in reservoir sites. Worldwide clinical trials based on the initial "cure" now must all be re-evaluated.
So, with all the talk of cures, there remains only one apparent cure, which is that of Timothy Brown, the "Berlin patient" who was treated with a stem-cell transplant for his leukemia with cells from a donor whose cells did not allow HIV to enter them due to an uncommon mutation.
This approach is still not ready for prime time.