High-activity antiretroviral therapy (HAART) first arrived in 1993, comprised of a variety of agents active against human immunodeficiency virus (HIV). These included fusion inhibitors, integrase inhibitors, protease inhibitors, NNRTIs and both nucleoside and nucleotide reverse transcriptase inhibitors. Currently a three-drug regimen, HAART profoundly revised the life expectancies of a great many, including even some whose disease state had proceeded to a point near death.

In 2012, a two-drug combination, tenofovir and emtricitabine, or Truvada, was approved by the FDA for preexposure prophylaxis (PrEP).  While this has demonstrated remarkable prophylactic efficacy against HIV, the at-risk community has always been advised to continue basic HIV prevention strategies, not least being the use of condoms for sexual activity and the use of sterile needles for drug injection. 

Unfortunately, that very effectiveness has provided many people with the belief that the inconveniences of condoms and of obtaining sterile needles need no longer be supported.  This has been a particular concern for those of us who care for people with addictions. Ours is a population notoriously susceptible to self-deception; and always at risk for employment of that most primitive of defenses, denial. The fact that most intoxicating substances are solvents of judgment, at the same time that they may stimulate or even facilitate erotic satisfaction, doesn't make intervention any easier.

The principal intent in raising this topic, other than to acknowledge December 1 as having been World AIDS Day, is to remark how surreptitiously HIV slipped into the population to begin with; and to ask whether we are so very sure that a similar infectious agent could not do so again. It's a rhetorical question; rates of transmissions of old, mundane acquaintances such as gonorrhea and syphilis are re-ascending, indicating the lack of community caution and concern. Parallels to the HI(V) retrovirus already exist in the human population, such as the human t-cell lymphotrophic virus (HTLV) series; others, with mutation, await admission.  Prions, such as that causing Creutzfeldt-Jakob disease, could be the next invasive candidates, although current animal studies do not yet support the notion of sexual transmissibility.  Worth recalling is that there was a five-year interval between the 1980 MMWR report of the immunodeficiency syndrome and the development of an ELISA serologic study for HIV antibody, permitting population screening and diagnosis. 

The summary is, there is no evidence that PReP has any preventive benefit for agents other than HIV. Our patients, engaged in addiction, cannot be expected to have any better judgment now than their predecessors had in the 1970s and 1980s. Surveillance only works when the threat is known, and the next epidemic may already be underway.  A major element of our role as addiction specialists is to convey knowledge of those risks to our patients.

- Editor-in-Chief: William Haning, MD, DFAPA, DFASAM