I had a scare and took PeP this year. I had to ER shop. First one denied me coverage and made assumptions. I ended up getting care at a cost of ~$6000 to my insurance. I paid $270. I have great healthcare but this is obscene. I don’t want to get sick and die. I was being careful but accidents happen.
Yes, according to my statement this is the actual amount paid by insurance. Most of it ($4500) was for my two prescriptions. The rest was for 2x ER visits (first doc denied me), and one round of labs.
If I'm understanding correctly, t34543 was treated with PEP rather than PrEP; even with a relatively expensive drug combination (Truvada/raltegravir) this should cost about £850 at NHS tariff prices.
PrEP should be really cheap (~£10/mo) but the generic status of Truvada (emtricitabine and tenofovir) is being held up by legal shenanigans, so the NHS tariff price is currently £355.73/mo for the branded formulation. This has obviously severely constrained availability on the NHS, so a lot of at-risk individuals are just buying the generic online.
> It has been estimated that the average lifetime cost to the NHS for a person living with HIV is £360,000. Around two thirds (68%) of these costs were for anti-HIV drugs. The cost of a year’s HIV treatment is about £11,000 and of PrEP £5,000. The NHS obtains Truvada at a cost of £3,000–£4000 per person per year. People need to take HIV treatment for the rest of their lives but PrEP will generally be needed for a much shorter period. It is believed that the patent for one of the key drugs in Truvada, Tenofovir, expires in 2017, slashing the cost of the drug from this time. There has been a collective call on Gilead, from those involved in PrEP activism, to lower the price of Truvada for use in PrEP, as there are concerns that PrEP may not be deemed to be affordable.
Well, PrEP is a miracle drug that has gone criminally underutilized in the fight to eradicate HIV. It would be nice to see governments really push it hard for a change.
In many countries it's easy and relatively cheap the get. It's horrible it's only available with insurance and high costs in the US.
For those curious; in Australia, it's prescribed and costs about $50-60 p/month. In the UK, it varies; England and Wales are doing trails, and Scotland it's prescribed. Under the NHS, it's £9. In Canada, the generics cost upward of $300 per month.
The drug has several non-minor side effects, is prohibitively expensive, and is the same as the treatment for someone who already has the virus. I for one think it's improper to prescribe a drug with these nephrological side effects to a large number of otherwise healthy individuals, not even accounting for the cost.
If it weren't for Gilead's legal efforts to extend the patent on Truvada, it'd be a dirt cheap generic by now; it already is in many countries.
You might think it's improper, but the evidence says otherwise - PrEP is safe, well-tolerated, marginally cost-effective at proprietary prices and clearly cost-effective at generic prices.
One of the fundamental principles of modern medicine is informed consent. Patients have the right to make their own decisions about their treatment based on their own assessment of the risks and benefits. PrEP is an incredibly compelling proposition for a lot of patients.
I think PrEP is great and I don't think we do a great job of getting it to people for whom it makes sense. That being said, the CDC has an excellent position on who should be getting it and that's not a lot of people.
PrEP is well tolerated given it's known side effects but conservative medicine dictates that we don't prescribe medications unless we have a measurable benefit and that's not a large group of people. A homosexual male who has lots of unprotected sex with strangers should probably be on it. A hetereosexual mostly monogamous person probably shouldn't be.
A big factor here is that the prevalence of HIV in the US is low, at .34%. Globally it's a bit higher at .48%. It is also often not that contagious. That being said, under the right circumstances it could be so it's real important to be aware of the risk factors.
They were speaking of medicine rather than policy, and getting it wrong. PReP is not the same course as treatment, and prophylaxis is always a thing given to healthy people rather than sick ones. The side effects are considered manageable: you watch for signs of liver problems and you don't give the drug to people prone to them.
I'm not a doctor but I can read the prescribing information[1], which they don't seem to have done.
Arguing the facts is totally good. And you may very well be right (I don't know anything about the subject). But attacking the commenter's position because he/she is not a doctor (like you are not a doctor), struck me as poor form.
Of course. In many circumstances, the experts don't even agree. It's incumbent on me to inform myself, and I can lean on those very experts, but I'm not at all comfortable ceding how to weigh those tradeoffs to the people who identified them scientifically.
I'm not necessarily saying you ought to cede to the experts, I'm saying you ought to do the research they have already done if you expect them to take you seriously about changing the way they do their jobs.
Obviously it's not breaking any laws to post an uninformed opinion on the internet, but what is going to be accomplished by it?
My husband and me both take prep, his first Doctor refused since it promoted "promiscuity" and would only prescribe it if you are in a relationship with someone positive.
Which is bull.
Find a new doctor that is actually sex positive and won't refuse it for stupid reasons.
(Admittedly I am lucky where I am though to have a doctors office that focuses on LGBT issues, which happens to include HIV prevention/care)
Yes, that is the case. Tenofovir and emtricitabine are generally well-tolorated. They can affect bone density and kidney function and this should be monitored; the majority of people experience no side-effects.
Go to a doctor or clinic that focuses on the LGBT community. It's very easy to get, and they'll take care of setting you up on the Gilead copay assistance program, so the medication should be completely free. Their program will cover up to $7,200/year in copays.
You can get it prescribed online. I think you just video chat with a doctor, then they prescribe. Plushcare and Nurx are 2 sites I found just by searching.
Perhaps more countries should follow Thailand's approach:
On January 25, 2007, Thailand’s interim government issued compulsory licenses–which require
manufacturers to license generic versions of their patented drugs–for two Western medicines:
Kaletra, an advanced anti-AIDS medicine manufactured by Abbott; and Plavix, a blood-thinning
treatment to help prevent heart disease, produced by the France-based Sanofi-Aventis and U.S.
firm Bristol-Myers Squibb. These attacks were preceded in November 2006 by a violation of
Merck’s patent on the anti-AIDS drug Stocrin.[5] The government threatened to break
patents on eleven more drugs.[6] Explaining the rationale behind Thailand’s decision, health
minister Mongkol Na Songkhla said that “the move is permissible under international trade
rules in the event of national public health emergencies. . . . We have to do this because we
don’t have enough money to buy safe and necessary drugs for the people under the government’s
universal health scheme.”[7]
> On January 25, 2007, Thailand’s interim government issued compulsory licenses–which require manufacturers to license generic versions of their patented drugs–for two Western medicines: Kaletra, an advanced anti-AIDS medicine manufactured by Abbott; and Plavix, a blood-thinning treatment to help prevent heart disease, produced by the France-based Sanofi-Aventis and U.S. firm Bristol-Myers Squibb. These attacks were preceded in November 2006 by a violation of Merck’s patent on the anti-AIDS drug Stocrin.[5] The government threatened to break patents on eleven more drugs.[6] Explaining the rationale behind Thailand’s decision, health minister Mongkol Na Songkhla said that “the move is permissible under international trade rules in the event of national public health emergencies. . . . We have to do this because we don’t have enough money to buy safe and necessary drugs for the people under the government’s universal health scheme.”
Are you using an app such as Materialistic or Hews, or just using your browser? For what it's worth I don't recall any problems reading quote blocks on Materialistic.
I've checked and it's € 50 a month in the Netherlands for the pills. There is something else going on with that pricing. There are doctor fees on top of that, but a few checks a year will never consitute the $15k difference.
I can confirm in the US it is truly that expensive (which is fucking crazy). I have pretty good insurance (or at least the best I can get self-buying) but I still have to pay 30% of meds costs. That is something like $400 /month. Luckily Gilled will reimburse up to 7500 /year.
Fucked up private insurance in US, they charge that much and then do the reimbursement so they can bill the huge monthly cost to plans / government that will cover it.
We should be giving this out for free.
My MD said Truvada might go generic next year, so perhaps there's hope.
In the US, we’re paying obscene prices because no other country pays their fair share to recoup the cost of development plus bringing the drug to market plus a reasonable margin for the effort.
The US should establish an agreement whereby US patients pay a LOT less but that the foreign patients need to pay the same.
The amount the industry earns should be low enough to make it reasonably financially accessible to patients but high enough to prompt our best and our brightest to pursue new drug development as a career.
> During the quarter [2019 Q2], Gilead generated $2.2 billion in operating cash flow, repaid $500 million of debt, made dividend payout of $800 million and spent $588 million on share buybacks.
> Adjusted product gross margin was 87.3% compared with 84.2% in the year-ago period. Research & development (R&D) expenses were relatively flat at $916 million. Selling, general and administrative (SG&A) expenses increased 20.8% to $1.01 billion.
You're basing your argument on cherrypicking one single pharmaceutical company that is doing exceptionally well recently because it had the second best selling drug of 2018, Harvoni, a drug to treat Hep C.
What about when you take all the pharma companies and average how well they do over several years? The average net profit margin for the industry is 14.05% according to a January 2018 study by New York University’s Stern School of Business.
14.05%, not great, not terrible.
In addition, the overwhelming majority of those dividends and share buybacks from one company are subsequently plowed back into the industry in different companies depending on which of those companies are working on the most profitable drugs.
source: I have several friends that control a lot of AUM that specialize in pharma investments.
> You're basing your argument on cherrypicking one single pharmaceutical company that is doing exceptionally well recently because it had the second best selling drug of 2018
Well, the discussion was about the atrocious cost of HIV medication, and Gilead is the company that holds the patent on Truvada. You didn't provide a link, but http://pages.stern.nyu.edu/~adamodar/New_Home_Page/datafile/... suggests it's actually lower in 2019 at 10.94%.
From the linked Excel sheet there, there are 28 industries with higher net margins, and 65 with lower net margins. They're still doing just fine :).
28 with higher net margins and 65 with lower net margins.
As I said, not great, not terrible. They're doing just fine, but they are also far from abusing their position. An industry abusing its position would be one with higher net margins than almost all other industries. The fact that 30% of industries have better net margins suggests that this industry is far from being abusive in its pursuit of profit while improving people's quality of life.
14.05% Is FUCKING GREAT considering they make their money over the misery of people. It's actually a disgrace that the profit margin is anything over 2%.
14.05% is perfectly reasonable considering they are giving people hope for a better quality of life.
Profiting off someone's misery would be when you cause the problem and provide the solution. If you merely recognize an existing problem and provide a solution where there previously was none or where the previous solution was inadequate/inferior.
Attitudes like yours makes me not want to continue using my talent to create on solutions to problems that qualitatively and quantitatively improve people's lives. If people are going to look at it as profiting off misery and deny me the opportunity to increase my wealth, I and others will just take our talents elsewhere. There is no lack of other industries and problems where those capable of contributing solutions can make money and not be subject to your shitty attitude towards how they make a living.
Lastly, I say all this as someone who takes an orphan drug myself that would not exist at all if the US didn't have a legal framework that gives pharmaceutical companies the incentive to bring drugs to market. The drug I take is available in only one other country and only because a US pharmaceutical company brought it to market.
I don't agree at all. No profit should be had for developing medicine. You deserve a nice salary for your work but no profit should be made by the company.
a person who is sick is just a person who is sick. They don't become a consumer until they consume something and for that you need someone to produce something to consume. A consumer is defined by consumption. Consumption is only possible if there is something to consume. They is only something to consume if that something is produced/created. That means that someone cannot be a consumer without the people who create whatever it is they consume.
This is pretty simple semantics. Not sure what you're struggling to understand here.
I once presented to the monthly board meeting of one of the biggest global pharma companies. The audience was the top execs plus the top-10 country heads.
All they talked about during the dinner was price fixing, tricky deals to block generics, and schemes to maximise the amount they could get each country to pay. Nothing about the science, medicine behind the drugs, or benefits to patients.
Not just pharma. Most industries care about increasing profits and blocking competitors. Hardly surprising since Top execs are measured on such metrics.
Pricing is always and inevitably what the market can bear, not anything about “fairness”. If prices are too high or communities are too poor (communities not countries), those communities go without. Right now, the US is so expensive that in cases like this it makes sense for patients to fly to another country to get the medicine. That’s unsustainable.
It fundamentally is about fairness albeit in a peripheral sense - the market doesn't exist in a vaccuum - those high prices depend upon granted monopoly rights and regimes which are a bargin wrongly conflated with property and treated like an entitlement instead of the contracts they are. Nothing is owned - only the ability to stop others from doing things. An unfair contract is increasingly likely to be ripped up because there is nothing more to be lost by doing so.
That people are flying abroad is the start of ripping up their local monopoly along with uncertifified online pharmacy importation and grey market sales - taking risks to avoid costs is a sign that the market /isn't/ bearing it.
The reason markets don't really work well for healthcare is that 2 things efficient markets require are competition and symmetrical information. Drug companies have exclusive patents. Doctors require extensive licensing that limits the labor supply. Prices are not transparent from providers. And maybe most importantly, in many cases people don't really have a choice whether they want to participate in the market or not; it's sometimes a choice of "pay whatever they say for treatment" and "die".
Since when the market knows the word fair? You charge as much as you can, in this case Americans are the suckers, but if it makes you feel any better for yourself and natural pride keep calling it as you pay for the whole worlds market.
Oh look you created an incredibly inefficient, expensive and corrupted system to research drugs and now you claim you spend more on drug research than anybody. Have a pat on the back.
Can you substantiate your rant with facts? The U.S. for decades has been the leading country in drugs r&d and other countries do use the results of it on subsidized terms.
I find this SO hard to believe. It just does not pass the bullshit test, you know?
How come the US spends zillions on drug research and then sells that research for pennies to everybody except themselves?
I mean the logical conclusion to me, is that the real value of this drug research is in fact much lower than the pharma industry pretends it to be, hence they can't sell it for such insane prices abroad as they can in the US where they control regulation.
ABPI - Association of the British pharmaceutical industry. That's not a source, that's propaganda, so we're back to the default: What has been brought up without proof can be dismissed without proof.
One reason pharma R&D is higher in the US is that the general costs to bring a product to the US market are far higher than in other countries (e.g. the requirements of the FDA are costlier, see: https://www.sciencedirect.com/science/article/pii/S2452302X1... )
Monosopy doesn't depend upon anything the US does. They have local control of IP even if they tied it to others.
There would be costs involved but they can always tell them to get stuffed and manufacture their own if they won't be reasonable. Notably there is a lack of pharmaceutical companies who decide to abandon world markets entirely because positive N is always greater than 0.
I am not sure this explains the discrepancy between the healthcare cost between US and Switzerland.
More in depth analysis:
"There were two causes of this massive increase: government policy and lifestyle changes.
First, the United States relies on company-sponsored private health insurance. The government created programs like Medicare and Medicaid to help those without insurance. These programs spurred demand for health care services. That gave providers the ability to raise prices. A Princeton University study found that Americans use the same amount of health care as residents of other nations. They just pay more for them. For example, U.S. hospital prices are 60 percent higher than those in Europe. Government efforts to reform health care and cut costs raised them instead.
Second, chronic illnesses, such as diabetes and heart disease, have increased. They are responsible for 85 percent of health care costs. Almost half of all Americans have at least one of them. They are expensive and difficult to treat. As a result, the sickest 5 percent of the population consume 50 percent of total health care costs. The healthiest 50 percent only consume 3 percent of the nation's health care costs. Most of these patients are Medicare patients. The U.S. medical profession does a heroic job of saving lives. But it comes at a cost. Medicare spending for patients in the last year of life is six times greater than the average. Care for these patients costs one-fourth of the Medicare budget. In their last six months of life, these patients go to the doctor's office 29 times on average. In their last month of life, half go to the emergency room. One-third wind up in the intensive care unit. One fifth undergo surgery. "
You can read the rest it is very informative. I still don't think that healthcare cost in the US is caused by the rest of the world not paying their fair share in drug discovery.
> For example, U.S. hospital prices are 60 percent higher than those in Europe.
That's a rather weird statement.. I suppose it's true in some sense, but what I'm reading online from real people in the US is that they get bills that are easily 10-100x as much money for going to the hospital than I get.
There's a few others I wonder about:
> These programs spurred demand for health care services. That gave providers the ability to raise prices.
At least requires some numbers, because I'm constantly hearing about Americans not going to the doctor because for the real fear it might bankrupt them.
> The healthiest 50 percent only consume 3 percent of the nation's health care costs.
This is also questionable. Again maybe technically true, but not suitable for conclusions.
The ailments, pain and other bad stuff that Americans will walk around with instead of going to the doctor is incredible (again for the real fear it might bankrupt them). In the US I spoke to a real person who was trying DIY dentistry. There was an AskReddit thread about what general advice doctors say people shouldn't do, and the top advice was: don't perform operations on yourself.
I'm pretty sure it's the price driving down demand.
> The U.S. medical profession does a heroic job of saving lives.
Wait, why does it suddenly stop comparing to the EU?
> But it comes at a cost. Medicare spending for patients in the last year of life is six times greater than the average. Care for these patients costs one-fourth of the Medicare budget. In their last six months of life, these patients go to the doctor's office 29 times on average. In their last month of life, half go to the emergency room. One-third wind up in the intensive care unit. One fifth undergo surgery.
And this is different in the EU because ... ?
I don't like these statistics. I think they're using them to lie with.
dillondoyle>> Fucked up private insurance in US, they charge that much and then do the reimbursement so they can bill the huge monthly cost to plans / government that will cover it.
I was reflecting to this. If drug cost is part of healthcare cost than by definition it cannot be apples to oranges comparison.
But that's the payment after co-payment by insurance or third party (in case of GGD the municipality). For a fair comparison I looked up the over the counter price of the generic medicine (or to be fair, public news about that price, I didn't look in the price register). My conclusion is that in the US case it's somewhat unfair to blame the insurer if the base price of a medicine is amplified about 20 times.
My friend who’s on a high-deductible plan says they reimburse you for the portion that’s before your deductible. It’s actually kind of a sweet deal because you hit your deductible without being out any money. Then you don’t have to worry about paying for medical care for the rest of the year.
Who is “they”? There’s a copay card you can use from Gilead that helps pay your co-pay but not aware if that helps you hit out of pocket expenses before you hit your deductible or if that counts as your copay.
The way it was explained to me is: you use the Gilead card to pay you copay, and that counts toward your deductible. So, my last post was wrong to use the word “reimburse”.
That's insane. In Kenya, PrEP is offered free of charge in all public hospitals while in private hospitals, brand name drugs will set you back about $35, while generic equivalents cost about $4.
WHAT!? Here in Germany, my PrEP costs me €40 per month, and I only have to pay that because it’s one of the rare things that insurance doesn’t cover here.
yeah, shocking. if you have diabetes or a thyroid issue or hiv or really any chronic disease that requires medication you are out 12k a year easy, 6 for your insurance premiums and 6 for the deductible and copays. if you are broke there are some provisions, but if you are above the poverty line you gotta pay.
Is this true for health insurances paid by the employers too? I am just curious since people say if you have a tech job you have nothing to worry about healthcare in the US.
In many cases the premium is paid for by your employer entirely, and the max out of pocket is lower, like $4k a year. But it depends on the employer and what plans afte offered.
Also about 20% of Americans are on medicaid, and generally do not pay any premiums, deductibles, or copays
I have 20 years in c++ dev experience at an f500, in silicon valley I probably would get double the pay and full health benefits, but I probably would be too old to work there. so it depends on what you mean by tech.
That's insane. In the UK the NHS doesn't supply it yet, and GPs won't officially recommend it. But you'll find the NHS clinics quite often recommending prep purchase through international websites and referring you to HIV charities.
It costs about £30 pm in that case which is about $40
Often they'll be running studies at the same time to assess the feasibility of Prep on the NHS.
Unless PrEP succeeds in eradicating HIV (which might be possible if enough people are on it to limit the spread of the virus), it seems tailor-made to breed resistance. We don't generally give antibiotics prophylactically. Using anti-retrovirals this way seems like a bad idea from a drug resistance perspective.
I wonder if that's true though. I don't have a medicine background but I'm loosely following this development. I think the term drug resistance became popular with all these tuberculosis cases. What happened was that people got TB, they went to the doctor and got medicine. Then things got better and people felt healthy again so they stopped taking their medicine. BUT in reality they were supposed to take it for a longer period of time and then TB broke out again. And thus becoming drug resistant.
Right. For resistance to evolve, some part of the treated population must survive. (You can't evolve resistance to atomic weapons dropped on your head.) Is PReP really effective enough to ensure that there are no survivors? Sure, maybe it is, used correctly at therapeutic doses.
What if it becomes common enough to get into the water at much lower doses? What if people split pills to reduce costs? ISTM that there are many potential avenues for evolving resistance.
It doesn’t really work like that because of the lifecycle of HIV.
If someone is using PrEP and is exposed to HIV, then either the drug works and they avoid infection (in which case there is obviously no impact on drug resistance) or they become HIV+. But in that case, they were either exposed to an already-resistant variant, or they were astonishingly unlucky and the drug failed to prevent infection - in which case, resistance is a moot point.
A person needs to develop an active HIV infection in order to communicate the disease to another. PrEP prevents this from happening in the first place.
Or the person was not taking PrEP as prescribed, either missing doses or taking it inconsistently. Once they're infected, if they keep taking just Truvada, then that strain will begin developing resistance, which they can pass on, potentially to others taking PrEP correctly. There have been I believe 6 cases of people being infected with resistant strains while in PrEP.
That's why it's important for people taking PrEP to be screened regularly, and put on a proper cocktail if they test positive.
It is not about who the drug is being intended for -- it is about who the drug is being marketed to.
For example there's a massive campaign targeting both men and women engaging in any sort of sexual activity that includes fluid exchange promoting usage of PrEP. One can see it in a subway and on local commercials on TV.
Yes. NYC, specifically. It dropped off a bit during the summer, but it was all over the subway/local TV channels in the spring.
There's some new campaign now which unfortunately i don't quite recall but it is highly bizarre. It something along the lines of "equality. make hiv undetectable. Truvada for PrEP." or something like that.
Accidental sharing is very much a thing; it's not just needles and syringes that pose a risk, but other injecting equipment like spoons and filters. Nobody is infallible, especially intoxicated people, but that's no reason to deny them the benefits offered by PrEP.
I always felt like the only way you can eliminate the spread of a highly adaptive std is to develop a low barrier on-the-spot test administered just before intercourse at the latest or some point reasonably earlier in a date or whatever. This would still fail under the dormancy period viruses assume but it should improve the odds I'd imagine for those connected in one way or another to promiscuous sexual networks.
A test exists. It's good but not perfect. If you have the disease it will return positive 99% of the time. If you do not have the disease it will return positive about 1% of the time. About 0.1% of the population has the disease. You take the test. It returns positive.
What are the chances you have the disease?
People on HN may be able to work this out, but I guarantee that many people (including doctors and nurses) can't.
See Gerd Gigerenzer's work on this in Reckoning With Risk or Risk Savvy.
1000 people take a test. 1 of them has a disease, and the test will probably return positive for that person. 999 of them do not have the disease, and the test will return positive for about 9 of them.
That 0.1% includes newborns, the distribution of hiv is definitely not uniform. What are the chances if the person in question is a gay man that uses the test before unprotected receptive anal sex with newly met strangers?
since all porn talent on all non-underground shoots is supposed to only engage in sex with others (on and off the set) who tested negative and since the new talent has to test negative first time weeks before the talent enters the pool even the look back tests are very effective.
>Would you bet the rest of your life on a casual test like that?
On an individual level, this doesn't guarantee much, but on a population level this could provide a huge benefit. You yourself might not feel confident based on the test, but it would likely severely limit the spread of STDs (as long as treatment is available and accessible).
The main benifit of a bed-side test isn't that it informs the person who is infected. It is that it informs the person who is not infected.
Currently, most people who ask about STD status just take their partners word. Maybe a particuarly paranoid person will ask to see actual lab results, which could reasonably be months or years old at best (how often do you expect people to get tested?) or maliciously forged at worst (hopefully rare enough to be irrelevant at the population level).
With a bedside test, you get up to date information (subject to the quality of the test) on if you are about to get exposed, and can avoid the exposure if necessary.
There is still the cultural issue of needing to test your partner before an interaction, would might come across as prohibitively offensive.
HIV transmission is not so easy; last I checked, the rough odds of transmission from a single act of unprotected vaginal sex with a HIV+ partner was around 1 in 500.
If the test is 99% accurate, and your partner isn't in an obvious high risk group, it may push the odds into "less risky than other behaviors you commonly accept" territory.
In developed countries most HIV transmission is due to anal sex between men who have sex with men, where the odds of transmission per single act are more like 1 in 30. The transmission is much more heterosexual in Africa however, where most of this resistance is happening. [1] I'm kind of confused about the sexual practices that could cause this to happen, but I'm sure prostitution and rape (which increases transmission odds due to trauma) are involved.
What is your source for the 1 in 500? The numbers I found on the same website indicate an even smaller risk
https://www.catie.ca/en/pif/summer-2012/putting-number-it-ri...
However, "As you can imagine, accurately tracking the number of times a person is exposed to HIV is very difficult".
I don't recall; the numbers on Catie (~1 in 1250) are more modern and certainly a better estimate.
Either way, you only have to add a few more digits of risk mitigation and you're more likely to die in a car accident. A test that had even a 1% false negative rate would cover most of that ground.
I know nothing about this topic and I'll admit that I even had to google what 'PrEP' is, and I have a vague feeling I'm stepping into a minefield asking this question, but who is "everyone at risk" in this context?
> Straight men/women can easily have it and one fuckup and you can be infected
The probability is low though, and apparently there are side effects. We also don't preemptively dish out antibiotics for similar reasons: they won't do you any good unless under very specific circumstances and you will likely experience side-effects. Do no harm.
But the plan for prep also specifically includes you going into the doctor every 3 months to not only test for those side effects but also for a full STD panel. (Source: my husband and me are both on prep)
Just saying that "at risk" people should be trying to prevent this ignores a large portion of the population to try to stop its spread.
Thankfully a vaccine is in testing now, but if this was a vaccine most people would probably not question taking it.
So why is a pill to protect against something like HIV so much different?
My point was that "at risk" means "seriously at risk", not "well, you are theoretically at risk, so better safe than sorry". If you're statistically not very likely to be infected, the side effects may outweigh the good.
> if this was a vaccine most people would probably not question taking it
Doctors would, or so I hope, not recommend taking a vaccine with serious side-effects without a reason. You typically don't get vaccinated for Dengue fever when traveling to Helsinki.
Maybe I should rephrase that, anyone in not in a monogamous relationship (and having sex) should at least discuss it with their Doctor and see if it would be worth them being on.
I find it shocking when I am talking to someone and find out they have no idea that prep even exists.
Do you know what the odds of contracting HIV for straight people that have non-anal sex are? Infinitesimal. Even when one of them is infected, the odds are less than one in a thousand exposures.
What you are describing makes absolutely no sense for straight men or women that don't have unprotected anal sex.
If you give penicillin to a million people, about two hundred of them will go into anaphylactic shock. Sometimes the tail risks for taking drugs are more harmful than the condition they're trying to prevent or treat.
> I don’t know enough about this, but if there is drug-resistant HIV couldn’t this affect PREP?
The resistance in this article is to efavirenz and nevirapine, neither of which is used in PrEP. They're not even in the same class of drugs - both are NNRTIs, whereas PrEP consists of two NRTIs (in a single pill).
#What -- In several geographically distant third world countries HIV is becoming antiretroviral resistant in ~10% of cases.
#Why -- No one is _really_ sure. The most popular hypothesis is that it happens when people go on and off the medicine. Why would people do this? Shame, access, and some mothers that went on only during pregnancy. WHO recommended a pregnancy only treatment until ~2015.
#Impact -- These resistant breeds can spread, presumably just like the other varieties. The people with it have a much worse prognosis than those without.
#PrEP -- All the other parent comments talk about it. Sure, it should be used more frequently. It's a bit of a pipe dream to see it used in the 3rd world.
Well, to be more clear on the #what: These are strains resistant specifically to efavirenz and nevirapine.
Both drugs are members of the same class of anti-retrovirals, NNRTIs, which aren't prescribed together, they are two alternatives of the same type of drug and are used in combination with other drug classes.
None of the people have resistance to anti-retrovirals in general, they have resistance to a particular class which is no longer recommended in the US (as a first treatment) but is still a go-to in Africa. There are multiple other drug classes that can be put together for effective treatment.
In the US, Efavirenz (brand name Sustiva) used to be one of the first-line recommendations, but has been replaced by other drugs with fewer side effects and higher barriers to resistance.
Importantly, no currently recommended starting regimens contain a member of the NNRTI class.
All 4 of the current US recommended regimens now contain an integrase inhibitor (Dolutegravir, Bictegravir, or Raltegravir)
The integrase inhibitors have exceptionally few side effects and are also very high barrier to resistance. Dolutegravir which is mentioned at the end of the article is especially good in this regard, to the point that it is the only drug currently used in an only 2 drug (vs 3 drug) combination therapy. The main thing that needs to happen is for these areas to transition off of these particular NNRTIs.
What purpose does the phrase "geographically distant" serve here? Seriously, why include that? Because, for one thing, while this site was started by an american, in america, its absolutely read all over the world, and two, HIV rates are highest in these "geographically distant third world countries". This is a really strange thing to post.
It meant (to me) that there are several 'pockets' of this happening simultaneously, it's not some local 'strain' or 'outbreak'. I thought it was a crucial thing to add, for nuance. Not sure why you're so agitated over this.
I think it's because the poster understood it as saying they were geographically distant "from us", rather than that they are geographically distant from each other.
root comment here. For the record I intended to use the term to imply that they are geographically distant from each other and the mutation is probably not from single parent.
That can still make them distant? Is Australia less 'distant' from Europe now that it takes 24 hours instead of 6 weeks to get there? In some senses, yes, but not in the sense that the GP used 'distant' (i.e., as a objective word for 'not adjacent').
and then it loses all meaning, because a pathogen that can travels within people who travel on planes is a pathogen unconstrained by geography. It was a very odd, and frankly, telling turn of phrase.
> But drug-resistant HIV might develop when people interrupt treatment, she suggests.
[...]
> People living with HIV might go on and off the drugs for several reasons.
They didn't mention the fact that in most countries for most medications people just don't take meds as they should. We see this for meds that are crucial to keep the person alive. Many organ transplants fail because the person fails to take meds correctly afterwards. We see this where patients need to pay for their meds and further treatment (the US) or where they get free meds and further treatment (the UK).
This isn't a few percent of people who take meds. It's over a third of them, maybe about half of them.
That is a real worry in all areas where chemicals are used to selectively kill something undesired. It isn't just microbes, weed killers have the same problems. There is a real worry that in "a few years" (how long is not defined) antibiotics will cease to be useful and deaths will skyrocket from things we currently considered minor infections.
There is some hope though: having a resistant trait is only useful if it helps you survive. Most resistant traits are "costly" to keep around. Thus if we stop using some treatment - completely stop - in 100 years it will likely become useful again as those "microbs" without resistance out compete those with it.
This article in Scientific American’s April 2019 [0] is an excellent article that introduced me some of the details of HIV treatment.
While it isn’t related to the primary focus of the parent article, it gives some useful context.
>> At the end of this first stage, the viral load stabilizes at a level that can, puzzlingly, last for many years. Doctors refer to this level as the set point. A patient who is untreated may survive for a decade with no HIV-related symptoms and no lab findings other than a persistent viral load and a low and slowly declining T cell count.
>> Eventually, however, the asymptomatic stage ends and AIDS sets in, marked by a further decrease in the T cell count and a sharp rise in the viral load. Once an untreated patient has full-blown AIDS, opportunistic infections, cancers and other complications usually cause the patient's death within two to three years.
>> The key to the mystery was in the decade-long asymptomatic stage. What was going on then? Was HIV lying dormant in the body? Other viruses were known to hibernate like that. The genital herpesvirus, for example, hunkers down in nerve ganglia to evade the immune system. The chicken pox virus also does this, hiding out in nerve cells for years and sometimes awakening to cause shingles. For HIV, the reason for the latency was unknown.
...
>> When the researchers reran the experiment, fit the data to the model's predictions and estimated its parameters again, they obtained results even more staggering than before: 10 billion virus particles were being produced and then cleared from the bloodstream each day. Moreover, they found that infected T cells lived only about two days. The surprisingly short life span added another piece to the puzzle, given that T cell depletion is the hallmark of HIV infection and AIDS.
>> The discovery that HIV replication was so astonishingly rapid changed the way that doctors treated their HIV-positive patients. Previously physicians waited until HIV emerged from its supposed hibernation before they prescribed antiviral drugs. The idea was to conserve forces until the patient's immune system really needed help because the virus would often become resistant to the drugs. So it was generally thought wiser to wait until patients were far along in their illness.
>> Ho and Perelson turned this picture upside down. There was no hibernation. HIV and the body were locked in a pitched struggle every second of every day, and the immune system needed all the help it could get and as soon as possible after the critical early period of infection. And now it was obvious why no single medication worked for very long. The virus replicated so rapidly and mutated so quickly, it could find a way to escape almost any therapeutic drug.
>> Perelson's mathematics gave a quantitative estimate of how many drugs had to be used in combination to beat HIV down and keep it down. By taking into account the measured mutation rate of HIV, the size of its genome and the newly estimated number of virus particles that were produced daily, he demonstrated mathematically that HIV was generating every possible mutation at every base in its genome many times a day. Because even a single mutation could confer drug resistance, there was little hope of success with single-drug therapy. Two drugs given at the same time would stand a better chance of working, but Perelson's calculations showed that a sizable fraction of all possible double mutations also occurred each day. Three drugs in combination, however, would be hard for the HIV virus to overcome. The math suggested that the odds were something like 10 million to one against HIV being able to undergo the necessary three simultaneous mutations to escape triple-combination therapy.
>> When Ho and his colleagues tested a three-drug cocktail on HIV-infected patients in clinical studies in 1996, the results were remarkable. The level of virus in the blood dropped about 100-fold in two weeks. Over the next month it became undetectable.
I think the scare of the HIV epidemic in the 90s is gone. Just from looking at how we have progressed thus far, just looking at HIV medication alone, gives me hope against news like this. Resistance will happen, but we will always outsmart it.
This comment breaks the site guidelines. Would you reviewing them and sticking to them when posting to HN? They include:
"Eschew flamebait. Don't introduce flamewar topics unless you have something genuinely new to say. Avoid unrelated controversies and generic tangents."
and "Please respond to the strongest plausible interpretation of what someone says, not a weaker one that's easier to criticize. Assume good faith."
Or some people take it and engage in risky sexual behavior because they're now on it. I know more than a few people like that. Not everyone is a backwards hick, you're just virtue signalling.
STI incidence among MSM using PrEP
Men who have sex with men (MSM), particularly those who have indications for pre-exposure prophylaxis against HIV (PrEP), are at high risk for sexually transmitted infections (STI). In a study of nearly 3000 MSM in Australia who were initiating PrEP, the incidence of new chlamydia, gonorrhea, or syphilis over the subsequent year was 92 cases per 100 person-years [2]. Nearly half of the participants were diagnosed with an STI during the study period, with 25 percent of participants accounting for 75 percent of all STIs diagnosed; the risk of STI was proportional to the number of sexual partners and frequency of group sex. These data highlight the importance of frequent STI screening for MSM using PrEP.
2. Traeger MW, Cornelisse VJ, Asselin J, et al. Association of HIV Preexposure Prophylaxis With Incidence of Sexually Transmitted Infections Among Individuals at High Risk of HIV Infection. JAMA 2019; 321:1380.
We should remember though that what this demonstrates is a high correlation between PrEP use and risky sexual behaviour. It does not suggest that PrEP use encourages that behaviour - I don’t doubt that in some cases it does, but it’s difficult to think it does so generally.
Honestly, if you ask just about anyone in the community you'll find the general agreement is that PrEP does result in the decreased use of condoms, so it's not surprising that there is a general increase of other STDs.
But as more people start using PrEP and get tested regularly due to the general requirements, it is possible that STD rates will decline, but we're probably a few years away from seeing that in the statistics.
PrEP treatment also mandates regular STI testing. I wonder if it's possible to control for the higher diagnosis rate (e.g. would have been infected anyways just now know about it). And what is a comparable rate for the same population pre-PrEP?
I'd agree with you honestly, I'd suggest however that it's a very small minority, who probably have other concurrent factors, like drug or alcohol abuse. This is not sufficient reason to gatekeep the drug from those who would be responsible, and frankly not even a point worthy of mention.
But that's a society problem, not an individual issue. If someone requests protection from HIV, that's a serious problem for them. Other STIs you can cure, or are not as dangerous in effects.
Lifestyle disease? I don't think I've ever read anything more calloused. Frankly, the attitude that "you deserve to die because you had sex" is unacceptably retributive.
Globally, there are at least 36 million people living with HIV. In South Africa, nearly one in five people have HIV. Without access to antiretroviral treatment, they are living with a death sentence. Calling this virus a "lifestyle disease" is factually wrong; while infections in Western countries are mainly limited to specific groups, the virus itself does not discriminate.
Your message seems, at least to me, to be quite judgmental.
I'm interested in helping people who make bad choices and people who have bad luck. It's not clear to me that one group deserves more compassion than the other.
The comparison to cancers is a bit odd - HIV is generally not regarded as a lifestyle disease, while of course many cancers do have a lifestyle component.
HIV is communicable; the time and money spent to target specific populations in an effort to reduce incidence of a communicable disease of course pays dividends in that fewer people will subsequently be infected.
And looking further down the road (albeit perhaps with optimistic glasses), with enough effort, it may be possible to eradicate it without our ever having discovered a true cure. So it makes at least some sense to work in that direction, but those efforts of course have a high cost.
I find it odd that HIV is not a lifestyle disease. Everything I know about it says that someone is at zero risk if they take lifestyle precautions. Is there some risk to someone who doesn't do drugs and is in a monogamous relationship? That is they might catch it from someone near them (like the flu from a cough). Or is the definition of lifestyle disease different from what I intuitively think it is, so HIV doesn't qualify.
I'm with you on helping people who have made bad choices. However I do agree with the poster above: HIV seems to be getting an out sized share of research compared to other things that kill more people.
> I find it odd that HIV is not a lifestyle disease.
When I think of a "lifestyle disease", the first thing that comes to mind is type 2 diabetes. The actual disease is part of a lifestyle of chronic behavior that is linked to this particular bad health outcome. Someone can contract it regardless of their lifestyle.
Sure, there are potential lifestyle components to the way that the HIV virus is transmitted. Some people exposed to this pathogen will contract HIV. Of those, some will develop AIDS.
But that doesn't mean that the lifestyle is the cause of the disease; the pathogen is the cause.
As for the higher-level judgment: some people want to do drugs, and most people aren't in (and don't want to be in) monogamous relationships. The health of these populations is just as valuable as any other, no? It's perfectly possible to do both of these things and be healthy; the fact that some pathogens can be transmitted via these media makes it worth fighting these pathogens (while also of course educating people to engage in these activities more safely).
> HIV seems to be getting an out sized share of research compared to other things that kill more people.
Oh, yeah, if that's the point, I absolutely agree with that.
An easy place to start is traffic fatalities. It's not difficult to reduce these, but it costs both money and willingness to change driving habits. And of course traffic accidents kill many, many more people than HIV.
And heart disease. And opiod overdoses. And medical malpractice.
This is a useless attitude that causes people to die.
In the real world, people are exposed to various risks. It is a risk to drive a car. It is a risk to play a sport. It is a risk to drink alcohol. Every time you eat, there is a risk that you choke and die.
Solving public health problems by saying “you should have take more responsibility” is not effective. But the goal is to reduce negative outcomes. We can regulate cars to make them safer. We can provide free programs to stop people smoking. And yes, we can provide alternative HIV prevention methods to people who aren’t reliably using condoms.
Anyway, your underlying point is wrong in any case, for two reasons - first, PrEP is more effective at HIV prevention than condom use, which would presumably mean in your view that not using is would be irresponsible. Second, there are obvious cases when people contracting STDs because they didn’t use condoms for sex do not bear personal responsibility, such as when one of a long-term supposedly-monogamous couple contracts a STD without informing the other.
You are totally wrong in both your assumptions about what I said:
1st) PrEP solely protects against HIV. It doesn't protect against any other kind of STDs whatsoever. What is your solution here really?
2nd) Has it was clearly stated, I claimed it was your personal responsibility if you contracted STDs for not using protection "when you should". In case it's not clear, example of situations where you should use condoms: When you pick up someone for a one night stand in a bar for instance. Yet you decided to construct a strawmen of marital infidelity to go on with your point.
3. There are some activities that you really don't want to do with a condom
4. How about we just don't fucking shame people for not wanting to use a condom as long as both (or all) parties agree. Especially when there is a drug like prep.
That's a clear overstatement for which I can't find any evidence.
Contracting HIV with unprotected sex is difficult (1/1000 for vaginal sex and insertive anal sex, 1/71 for receiving anal sex - all numbers for unprotected sex) [1], breaking a condom is also difficult (4% cases in anal sex between gay men - which is the higher number [2]). Meaning that contracting HIV while wearing a condom, is extremely difficult (0.05% in the worst hypothesis).
It's up to you then, to prove that PrEP is more efficient than 99.95% of times (while still disregarding that unlike condoms, PrEP doesn't protect you in any way from other STDs... yes, those STDs that people not using condoms and that think they are entitled to have other tax/insurance payers providing PrEP for them, are spreading around).
> How about we just don't fucking shame people for not wanting to use a condom as long as both (or all) parties agree. Especially when there is a drug like prep.
That depends if it's those people bearing the full cost of buying PrEP, or if they expect the state/insurance companies to do it for them.
Seriously, people need to stop with this negative side effects bullshit.
Yes there are side effects, there are fucking side effects to almost anything medical.
The side effects are minimal at worst considering you have to go into the doctor every 3 months for testing (both for the side effects and a full STD panel). If they notice an issue they take you off of it.
Condoms are not 100% though, neither is prep. Its just another option and if the US was not being gouged in the price of prep, the cost would not be much different than the cost of condoms depending on how frequently you are having sex.
I am showing personal responsibility by both myself and my husband using Prep and getting tested regularly.
> I am showing personal responsibility by both myself and my husband using Prep and getting tested regularly.
Can't understand why you need PrEP unless you or your husband have unprotected sex outside marriage. That's the personal responsibility needed for both you and your husband: not having unprotected sex with other partners.
Again, can't see why the state or the other people paying their health insurances should have to pay for your preferences when it comes to use a condom. Nobody likes to use condoms... yet, responsible people, do.
It's so simple to get condoms and wear them - or to just partake in a lower risk sexual activity. No one is forcing anyone to have risky sex: it's a choice, and just as we don't accept arguments that men's desires are so uncontrollable that they cannot be held accountable for rape, so we should be sceptical of arguments that a person cannot help themselves but participate in risky sex.
And Prep won't protect you against the myriad other horrible STDs apart from HIV/AIDs now will it?
>God forbid as a society we focus on the society as a whole instead of demonizing the choices that people make.
Well, if we're focusing on society as a whole, then it could be argued that your doctor is right for discouraging promiscuity, since STDs tend to affect society at large as they spread.
>So why the fuck is prep so different.
Because it's an expensive medication, it's the only effective "treatment" for HIV, and just like overprescription of antibiotics, excessive use of prep is leading to resistance. So, arguably, these personal choices have serious consequences for society.
And I think it's disingenuous to frame this as anti-LGBT and/or sex shaming. Yes, barring access to prep disproportionately affects gay men, but that's because gay men are the ones who predominantly need it, and their individual, ostensibly private sexual choices are impacting the rest of us.
The FDA hasn't approved condoms for anal sex, and the failure rate for latex condoms is high in that usage. And lambskin condoms, while stronger, are explicitly labeled as not being suitable for disease prevention.
One company has had one approved, the FC2 Internal Condom (previously called the FC2 Female Condom). You can buy a three pack on Amazon for $28.99. Insane pricing.
You know what costs even less, has zero side effects and protects you for a range of STDs instead of just for HIV? Condoms.
People on this thread are going around in circles arguing that:
1 - they are entitled to my taxes/insurance paying their expenses with PrEP, because they don't feel like using condoms.
2 - thinking it's reasonable, going around spreading all pretty kinds of STDs (that PrEP doesn't protect from) yet again, because they don't feel like wearing condoms.
So for the same reasons:
- No one should fund your child birth because of your personal preferences.
- No one should fund your ER visit because of your own personal preferences.
- No one should fund your mental health care because of your own personal preferences.
Where do you stop with the personal preferences? Sexuality? Being transgender? Choosing to skydive? Ending up in poverty? Having sex? Abuse victims living with depression and anxiety? Paying through the nose for the same private insurance as you?
I am not suggesting the above are personal preference, but some people use arguments that they are, and that people should be denied healthcare treatment because of it.
Your insurance is covering a lot more than you spend on healthcare, that's how insurance works (and makes a tonne of profit doing so). A lot of people take pharmaceutical drugs to keep themselves healthy, PrEP is one of the many.
I'm fully aware of the side effects, I'm one of the few who had a severe allergic reaction to it, that was a hellish few days I do not wish to repeat; but I'm still for people who can take it being prescribed it if it helps reduce risk.
As for cost, maybe the patent system needs an overhaul, or maybe drug companies should have the same price for all customers, or perhaps healthcare should be centralized and and the current dictatorship of insurance and drug companies reduced to mere socialism instead, but that's a whole other discussion.
You do realize that in the beginning I didn't even realize that the guy I was answering to is gay, right? That info doesn't show up anywhere in his comment.
Also, you do realize that absolutely all that I said, applies exactly the same to any sexual preference, right?
But of course, at the lack of any real argument against what I said, all that people like you can do, is to pull out some imaginary victim card.
Here is an idea for you, stop playing the victim and take some responsibility for your actions.
