This article appeared in The Globe and Mail on May 5, 1999.
By Rod Mickleburgh
The distribution of an expensive, so-called morning-after pill that could head off HIV infection should not discriminate against individuals who have risky, uprotected sex or inject drugs, AIDS activists contend.
Generally, the powerful combination drug therapy known as post-exposure prophylaxis is freely available only to health-care workers and sexual-assault victims who fear that they have been inadvertently exposed to the AIDS virus.
Although evidence is far from conclusive, some studies have shown a greatly reduced risk of contracting the human immunodeficiency virus if the month-long treatment is begun very soon after exposure to it.
In British Columbia, about 800 AIDS drug kits are already provided at no cost every year to occupational health workers who believe that they have been accidentally exposed to HIV, mostly through pricks from tainted needles.
But AIDS activists argue that the therapy, if proved effective, should be available to everyone.
"Once you make a distinction, you are putting a moral judgment on what is a treatment issue," said Louise Binder, co-chairwoman of the Canadian Treatment Advocates Council. "Do you stop treating lung-cancer patients because they caused their own problem by smoking?"
Michael O'Shaughnessy, head of the B.C. Centre for Excellence in HIV/AIDS that provides cost-free AIDS drugs to infected patients, agreed that it is time to debate the matter.
"It is a very tough issue for the public. Are we going to treat health workers accidentally exposed to the virus the same as some folks who might come for treatment just because they didn't care to use a condom? And what about injected drug users? Some of them share needles every day."
A study released in Victoria yesterday at the annual Canadian Conference on HIV/AIDS Research estimated that it could cost in total as much as $4-million to provide postexposure therapy to the large gay population in Vancouver's teeming West End.
The findings were based on close to 1,400 HIV-free individuals averaging three incidents a year of unprotected anal sex with infected individuals. The estimates assumed behavioural practices among West End gays gleaned from previous and ongoing studies.
The cost of treatment ranges from $530 to $903 a patient, depending on whether two or three drugs are taken. "That's still only a fraction of what it costs to provide ongoing treatment to HIV-positive individuals," said Sophie Low-Beer, who did the study.
The emerging ethical issue is yet another example of the many complex and diverse questions that continue to confront the AIDS community after nearly two decades of battling the lethal disease.
For instance, much as they might welcome evidence of effective therapy making it more difficult for HIV to take root, AIDS workers worry what impact that may have on preventive measures, such as safe sex.
"It's a very serious problem. We do not want word to be out there that there's a morning-after pill. There's a danger people might be less vigilant," Ms. Binder said, pointing out that the therapy far from being a pill, actually involves a rigorous regimen of strong drugs, with potentially damaging side effects.
"Anyone who understands toxicity is not going to find this is something they really want to do. This is a very difficult issue, and we really need a general policy for people exposed to the virus."
Glenn Hillson of the B.C. Persons with AIDS Society agreed that the controversial therapy is a slippery slope for those in the fight against AIDS. "But we're already living in a paradigm where a lot of high-risk sex is being practiced, and individual decisions are being made all the time."
Provided that the therapy is effective, the health-care system should provide it to everyone, he said. "It's not just saving lives. In the long run, it's also saving dollars."
This editorial in response to the above article appeared in The Globe and Mail on Friday May 7, 1999.
On a scale of irresponsible, irrational and just dumb things to do, shooting up with dirty needles and having unprotected anal sex are hard to beat. And yet people do both those things even though information is widely disseminated about HIV and how it is transmitted. Why people knowingly put themselves and others- at risk is an enigma of human behaviour, but it is not restricted to HIV.
Think of smoking. Despite all the evidence that it dramatically increases the chances of developing lung cancer, emphysema and heart disease, 30 per cent of Canadians still puff away.
Think of teenage pregnancies. Again, despite sex-education classes beginning in elementary schools, walk-in contraception clinics and all sorts of evidence about the hardships, health risks and diminished opportunities for both mother and baby, teenage pregnancies are running at about 46 per 1,000 in Canada.
Think of sexually transmitted diseases. A 1997 Health Canada survey reports that 27.7 per cent of men did not use a condom when having sex with a non-regular partner. The rate for women was 28.1 per cent.
We do not deny treatment or social services to these people on the grounds that they should have known better. In fact, when it comes to unwanted pregnancies, abortion and morning after pills are options in most parts of the country.
Yet, we seem to have a different standard when it comes to offering morning after pills to people who fear they may have become infected with HIV. Sexual assault victims and health-care workers exposed to the virus are offered a powerful drug-combination therapy known as post exposure prophylaxis. Although long-term benefits of the drug cocktail are not conclusive, some studies have shown a greatly reduced risk of infection, if the month long treatment is begun quickly.
But the same service is not routinely available to people at risk because of bad choices or foolish behaviour . People who have deluded themselves into thinking they are immune to obvious dangers, or thrown caution aside for a momentary pleasure, or are unable to deny a habit that has become an addiction must first persuade a doctor to prescribe the prophylactic treatment and then have the money to pay for it because pep drugs are not usually included in provincial drug plans.
This is two-tier medicine of the most pernicious sort. The pep therapy should be available to everybody who needs it, under the same terms as the morning after pregnancy pill: Patients are given a prescription along with a series of couselling sessions on practicing safe sex and using clean needles.
The cost of providing a month's worth of pep therapy is minuscule
compared to the ongoing costs of caring for patients with HIV
or full-blown AIDS. Nobody wants to encourage risky behaviour,
but it is not our place to judge who is entitled to treatment,
especially when dealing with such a dreadful disease.
For more information, contact:
Bonnie Devlin
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6
Tel: (604)806-8306
Fax: (604)806-9044