An Example of Broken Discourse

Apparently there is a daily pill called Truvada that can help reduce (but apparently not prevent) the transmission of HIV through unprotected sex.   Many public health agencies are promoting its use.

Apparently there is also at least one skeptic, a man named Michael Weinstein, who fears the pill may not be as effective as advertised, but more importantly is concerned that the pill's existence will reduce the use of condoms among at-risk men.

As I read the article (and I know zero about it on my own)  the ranking in terms of effectiveness is:  condoms+Truvada > condoms > Truvada > nothing.

The amazing thing to me is how broken the dialog about these issues appears to be.  Truvada supporters claim that there is a consensus on Truvada and that Weinstein is alone in his criticism, and that he is as bad as a "climate-change denialist" (eek!)

Weinstein claims that many others believe as he does but have been silenced by intimidation by the Truvada supporters.  Further, he argues that public officials who support Truvada are all paid off by the drug makers in one way or another.

Jeez, this all sounds so familiar to this veteran of the climate wars that it is just amazing.  And the real tragedy of this broken discourse is that both sides have a totally valid argument.  I have no doubt that Truvada provides incremental protection (even Weinstein's clinic proscribes it).  On the other hand, it is fairly "settled science" in the safety world that an easier-to-use protection method can actually reduce total safety by undercutting a parallel protection mechanism -- the drop in seat belt use after air bags were added to cars is a classic example.    Weinstein argues that Truvada use will reduce use of condoms, and thus undermine safety.  Truvada supporters argue that condom use is so low already, even after 30 years of education efforts, that the drug is better.  Essentially, Weinstein sees the baseline as men who use condoms and worry about them getting worse.  The other side sees the baseline as men who don't use condoms and argues the drug makes things better.

It is a shame to see two groups of people who likely are motivated by good intentions devolve into name-calling and ad hominem attacks.   Just read the quotes in the article - no one in the debate seems to acknowledge that the other side includes people of good will who simply disagree.


  1. Daniel Barger:

    In reality neither preventative is relevant as neither is completely effective BUT more importantly neither is going to be used scrupulously by those who should do so. HIV/HepC are virtually impossible to catch unless one shares
    needles or has sex with an infected person. (there are a few outliers in healthcare who contract these from inadvertent needle sticks but that number is microscopic). In a rational world NOBODY would get HIV as NOBODY
    would share a needle with ANYONE and nobody would have sex without proof that the prospective partner was disease free. We have social diseases for the fundamental reason that we are an irrational and irresponsible species. Attempts to solve this problem by technology is doomed as irrational people won't use ANY technology that
    interferes with their irrational choices.

  2. That's a shame:

    "The amazing thing to me is how broken the dialog about these issues appears to be. Truvada supporters claim that there is a consensus on Truvada and that Weinstein is alone in his criticism, and that he is as bad as a "climate-change denialist" (eek!)"
    If Truvada isn't actually a silver bullet the supporters should eventually find out the hard way, all by themselves - no? I think your job here is done.

  3. Sam L.:

    Mine's BIGGER. Mine's BETTER. (see Less filling/ better taste) Or, as the song says, "Let's call the whole thing off."

    The can both be right, and they can both be wrong. Life's a bummer.

  4. Russell:

    This sort of logic, "But they may make risky/bad decisions" was one of the key pillars that led the FDA to block the rapid oral HIV test for 20 (TWENTY) years. So it's interesting to see the public (ie - government) agencies now on the side of promoting better methods.

    I completely understand and agree that humans are generally comfortable with X risk, and adding things to mitigate that risk to X-1 will likely just lead to them making other changes that land them back at X. Your air bag example is a good one. Anti-lock brakes are another, where the next effect is that we tailgate more. However, I am very sensitive to the idea of any "public health agency" trying to manage my behavior to ensure I do what's best for me by their judgement. Even if this medicine did lead to me feeling enabled to take more risk... that's not the government's job to stop.

    I realize the larger point of the post is "Let's not call each other names". I agree. Two smart and informed people can disagree while still both being smart and informed... and (GASP) not evil. The denier label is particularly repugnant and the BIG appeal gets old. Labeling every opponent as part of a giant evil does nothing for discourse.

    Humans have a pretty long history of casting opposition as the "big evil" that must be defeated.

  5. Titan28:

    A vital angle to note is the high cost of the drug. Almost $20,000 a year. That little nugget, which was part of the story when the drug first materialized, has all but vanished, now that insurance and pharmaceutical companies are assured of a sweet payday now that the drug is approved. Why is the cost of health coverage going up? Look no further.

  6. MJ:

    Stated more succintly, adverse selection is real and abundant.