Filed under agit-prop

On the PBAC rejection of Truvada as PrEP

A couple of (lengthy) comments on the ‪#‎PrEP‬ decision today:

1. Don’t blame PBAC

We’re all angry and disappointed by this decision, but it’s important we’re clear where our anger is directed. A fair few of the comments I’ve seen in the last couple of hours have expressed anger at PBAC for making the decision the way they did. But it’s Gilead, not PBAC, we should be angry with.
PBAC operates to a very narrowly-defined mandate: its one and only task is to determine whether drug listing are cost-effective. For a novel intervention like PrEP, that means comparing the cost of what the drug company is offering with the cost of doing nothing. Simply put, if the benefit is greater than the cost, the drug gets recommended; in this case, the cost outweighed the benefit.

PBAC also only considers the application made by the drug company. To protect its profits, Gilead chose to make their application based on only approving PrEP for people at very high risk of HIV (specifically, those with a greater than 3% risk of infection in 12 months), and at a high cost (we don’t know the exact cost they quoted, but we can assume it’s not much different from the current PBS price of $750/month). PBAC quite rightly questioned how practical or feasible it would be for doctors to determine which of their patients had a greater than 3% annual risk of HIV infection, and made it crystal clear they would prefer to see an application that would make PrEP available to everyone who could benefit, at an appropriately reduced price.

Let’s be clear: those pills cost a few sets each to make, and Gilead had a choice about how to structure its PBAC application. It chose to take a path that would give it the best return while denying PrEP to the majority of people who could benefit from it. That proposal would have seen hundreds of needless HIV infections every year, because its not just people at highest risk who get HIV.

2. The language of the decision

A couple of phrases in the PBAC decision seem to have inflamed people’s passions. I think some clarity is needed.

“attempts to restrict the eligible population by quantifying an individual’s future risk of HIV infection based on self-reported future behaviour, and limiting access to those with a predicted annual risk of infection of 3% or higher, may not be feasible or acceptable to clinicians and consumers.”

This, I think, is unproblematic. PBAC is saying that Gilead’s proposal to limit the use of PrEP to people at high risk “may not be feasible or acceptable.” It would require clinicians to make an assessment of the annual risk of HIV infection based on the patient’s self-reported behaviour. This is likely to be both inexact and practically impossible – if you were a doctor, could you make this judgement in a meaningful way? As PBAC goes on to say, far better to make the drug more widely available and let doctors and patients decided together if they feel the benefit outweighs the risk for that person.

“The PBAC noted that the efficacy of Truvada was highly dependent on adherence, and that it is not clear if subjects at high risk of contracting HIV due to self-reported low adherence to safer sex practices would also have lower adherence to medication.”

This sentence has a lot of people riled up, who have characterised it as saying ‘if gay men can’t be bothered using condoms, why would they bother taking PrEP?’ I think the statement refers back to the earlier questions about the viability of limiting PrEP to people at high risk. Many people at highest risk of HIV have difficulty with safe sex for quite legitimate structural reasons – homelessness, poor mental health, substance abuse issues, low literacy, etc. Limiting PrEP to that group could artificially increase the proportion of PrEP users who have adherence problems (due to the same structural factors) and consequently, this may not be the most efficient way to use the drug. Again, if the price were lower, it could be prescribed based on patient choice rather than arbitrary criteria, and we know most medicines work best when used that way.

Today’s decision has been a huge disappointment, but it’s not the end of the road. It often takes several application to PBAC before a new drug or indication is approved, and Gilead should be encouraged to resubmit. But we as a community have to hold the company to account – its next application must be structured around delivering the best public health outcomes, not the highest profits. Gilead stands to make a lot of money out of PrEP, even if they reduce the price radically, which is what they have to do before we get the outcome we want and need. The gay community has been doing its part to combat this disease for 30+ years, while Gilead and other drug companies have profited massively from it. It’s time for them to come to the table and do their part to prevent, not just profit from, HIV infections.

In the meantime, unfortunately there will be dozens or hundreds of needless HIV infections. We need to do what we can to minimise those, and to care for the unlucky ones who slip through the cracks.

Pills cost pennies, Gilead’s greed is ruining lives.

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It pays to advertise.


Buy this shirt! Don’t blame me – I voted below the line

Don't blame me – I voted below the line
by paulkidd

Welcome to democracy, Australian style: you go into a polling booth and you get the choice of an impossible 4-dimensional Sudoku puzzle, or just tick a box labelled ‘cars’, ‘sport’ or ‘legalize weed’ and away you go. The end result? Well, you’re standing in it.

Show that you’re part of the solution, not the problem with this highly wearable garment.

GET IT HERE: in black or white. T-shirt sales support and keep me in beer.

Buy this shirt! Official T-shirt of #auspol

Official T-shirt of #auspol
by paulkidd

Your a idot mate its your lot are runing Austriala.

GET IT HERE: T-shirt sales support and keep me in beer.

Buy this shirt!

Dead (black or dark fabric)
by paulkidd

Dead - Dead - Next (black or dark fabric)
by paulkidd

A commemorative T-shirt to wear on the occasion of the Baroness Thatcher’s dispatch to the underworld.

GET IT HERE. T-shirt sales support and keep me in beer.

Marriage equality: how they voted

The table below (over the fold) shows how the marriage equality vote went down in the House of Representatives today. I might have something more to say about this in due course, but I’ll just post the roll-call for now.

(Based on the draft Hansard and there may be errors. Let me know if you spot anything wrong and I’ll fix it up.)
Continue reading


The great leap backwards

Queensland’s LGBT and HIV communities have been hit with a double whammy this morning, showing just how dangerous the new LNP government in that state is.

First came the news that the Queensland government is set to overturn the state’s civil union laws. With a new poll showing that 50% of Australians are in favour of marriage equality, and just 33% opposed, the reported LNP plans represent the opening of a new front in the war on queer civil rights in this country. But given the LNP’s opposition to the legislation when it was passed, it doesn’t come as a complete surprise.

Much more troubling is the announcement this morning that the government has, without warning, pulled all funding from Healthy Communities, the only LGBT health organisation in the state and the front line of Queensland’s HIV prevention effort. Formerly the Queensland AIDS Council, Healthy Communities has been continually funded by Queensland governments of all political stripes since 1988, and currently holds (or rather, held) government contracts valued at $2.6 million for HIV prevention and LGBT health work.

In a press release (PDF link) issued this morning, Healthy Communities has confirmed that 26 of their 35 staff will lose their jobs as a result of the defunding decision.

This is an appalling, short-sighted, ideologically driven decision that will hurt LGBT people in Queensland. Cutbacks in HIV prevention funding in Queensland and Victoria between 1998 and 2006 led to pronounced increases in HIV infections, and this will happen again now.

According to the Queensland health minister, Lawrence Springborg, Healthy Communities is being defunded because it has “lost its way” and that funding is “made available for health campaigns, not advocacy.” This shows just how out of touch the minister is – it displays a complete absence of understanding of the basic principles of health promotion and its smacks of an ideological approach.

Springborg says the LNP government will fund a new AIDS Council – there’s no detail on when that will happen or how, but we can expect it will be a timid, compliant body with no real attachment to the community it is supposed to serve.

Elsewhere: A thoughtful post on the decision on View from the Quarterdeck.

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Blacked out tonight in protest against #SOPA #internetblackout will be participating in the internet blackout in protest over the Stop Online Privacy Act (SOPA) tonight (Australian time). For 24 hours from 1600 AEDT (0500 UTC) the site will be online, but blacked out. More information.


I love this sassy (but NSFW – lots of F-bombs) promo for FCKH8, a fundraising initiative supporting the campaign against California’s Proposition 8 anti gay marriage bill.

More info about the campaign.

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Equal love


Today marks the sixth anniversary of the passage of the Marriage Amendment Bill 2004, the legislation that enshrined in Australian law the definition of marriage as being between “one man and one woman.” Australia’s DOMA.

The anniversary will be marked by rallies in all the capital cities and a number of regional centres (details), and it’s heartening to see support for equal marriage rights growing in Australia day by day.

Six years ago, when the Howard government introduced, and the Latham opposition immediately supported, this legislation, Brent and I were planning our own wedding, which took place in Canada later that year. I wrote a cranky blog post and very cranky letter to the editor at the time.

Brent and I were the first gay couple we knew to tie the knot. In those days, gay marriage was legal in The Netherlands, Belgium, and a handful of Canadian Provinces. Since then Argentina, the rest of Canada, Iceland, Mexico, Norway, Portugal, South Africa, Spain, Sweden and five US States have all legalised same-sex marriage. Finland, Slovenia, Luxembourg and Nepal are all committed to legalisation in the near future, and the subject is being energetically debated in many other countries. Same-sex marriage is a global phenomenon, and an unstoppable force.

I’ve been impressed by the degree to which this has become a political issue during the current election campaign. Julia Gillard has been asked repeatedly to explain her party’s position on same-sex marriage, and she has squibbed it every time. The ALP’s position on same-sex marriage (they’re against it, but for state-based “relationship registries”, as long as there’s no ceremony and no-one uses the ‘m’ word) is unsustainable within a party that claims to be progressive, and the party should adopt a more open-minded position. Unfortunately the ALP is scared witless of the political muscle of the Catholic Church and a few other religious minorities. That’s a disgraceful position for a party that claims to be socially progressive, and it partly explains the haemorrhaging of support to the Greens.

Julia Gillard could articulate a more open position on this issue, without unduly scaring the horses. She could acknowledge that it is an issue, for a start, instead of robotically chanting that ‘one man, one woman’ shibboleth. She could affirm that there will be no change in the short term, but espouse a personal belief that change will come when the nation – and the party – is ready. She could suggest we have a national debate on the issue over the coming term, and to develop a legislative response based on that. She could end the hateful and mean-spirited policy that prevents the issuing of ‘certificates of non-impediment to marry’ for same-sex couples intending marriage overseas. Or she could grow a pair and just say what we all know she, and Penny Wong, and probably most of the ALP party room, believes.

In the meantime the voices for same-sex marriage grow stronger and the arguments against it become ever more ineffective. We will win this – we have justice on our side; and a day will come when my Canadian marriage certificate will be recognised in my own country. In the meantime, my love and admiration goes out to all the hard-working queers who are keeping this issue on the agenda, organising the rallies, writing the petitions, fighting the good fight for equality and human rights.

See you at the rally.

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