> Even when viral load is undetectable, ... may have detectable HIV genetic material in ... semen, but there is no scientific evidence that such material is associated with HIV transmission.

What? Isn't that the primary transmission vector?

For context, the typical ejaculation from someone untreated contains between 10,000 and 1,000,000 copies/mL. With treatment, the average is 1-10 copies/mL.

Besides HPTN 052, there have been three other studies--PARTNER, PARTNER 2, and DISCOVER, of real-world (condomless) usage in mixed serotype couples

https://www.idsociety.org/science-speaks-blog/2021/u--u-the-...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942556/

> Findings from the breakthrough NIH-funded HPTN 052 clinical trial, a decade-long study involving more than 1,600 heterosexual couples, offered clear-cut evidence that ART that consistently suppresses HIV also prevents sexual transmission of the virus. In 2011, the HPTN 052 investigators reported that starting ART when the immune system is relatively healthy, as opposed to delaying therapy until the immune system has been weakened by the virus, dramatically reduces the risk of sexually transmitting HIV. The protective effect of starting ART early was sustained over four additional years of follow-up. Importantly, when viral loads were measured, no HIV transmissions were observed when ART consistently, durably suppressed the virus in the partner living with HIV.

Wild speculation is that the genetic material you mention is inactivated and therefore unable to transmit the virus, but is still detectable. I am just an internet rando surfing the knowledge graph, but the science appears sound.

https://www.nih.gov/news-events/news-releases/hiv-control-th...

https://web.archive.org/web/20150106032855/http://www.niaid....

https://www.clinicaltrials.gov/study/NCT00074581

Is there a similar study of gay men who are not in a monogamous relationship?

Studying the group with the lowest transmission rate who could still transmit seems kind of dishonest.

And yes, there is a similar study: https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

Edit: right, I'm also assuming the possibility of provirus mutation before this chain of events, and I don't think anyone can deny at least the mutation of HIV before it becomes a provirus.

Until then, I'll take the word of public health practitioners who've been steeped in the field for their entire careers. Their work has been significant enough to be published in Lancet which is a pretty good signal to this layman (though with a bachelor's of science in an unrelated scientific field, so no stranger to reading primary literature).

I think "can't" deserves at least something physically (as in physics) unlikely, not something that's been demonstrated in a DNA virus previously (and like I said, HIV in provirus form is not unlike a DNA virus).

i've no opinion on the topic at hand, but I would urge you to find a plethora of signals to form your opinions.

The Lancet has been responsible for quite a few negative 'public health' trends.

The Lancet is responsible, at least partially, for the whole 'vaccines == autism' thing of Andrew Wakefield's; and even ignoring that they have a history of poor review and retraction of work that ends up either being entirely wrong, or guilty of experimental misconduct.

In 1992 they published stuff that suggested a causal link between HIV infection and the oral polio vaccines.

In 1998 they published a (big tobacco funded) peper indicating that second hand smoke doesn't have as much risk as earlier thought.

In 2000 they published a study that claimed that St Johns Wort was as effective an anti-depressant as conventional SSRIs and TCAs.

Just because something has become 'prestigious' doesn't mean it should be trusted wholeheartedly.

But it's interesting to note that the way HIV generates its infamous genetic variability can result in a remarkably large fraction of the virions being mutated beyond viability.

https://journals.plos.org/plosbiology/article?id=10.1371/jou...

The infection risk would have to involve a factor of virions getting to a susceptible cell without getting destroyed anyway of course, but given that many of the contenders might not be capable of infecting even if they get there it seems even more understandable if one would usually end up with 10 as the number needed to satisfy some chosen level of statistical significance.

That's debatable. Injectable PrEP has been around for years already (Lencapavir is not the first, just the most recent). Lencapavir has also not yet been tested on all at-risk groups, so unlike other forms of PrEP, it's not a universal solution because it cannot be prescribed to all candidates.

Given the price, which is quite high even with the programs Gilead has said that it will issue to reduce the cost, it remains to be seen how widely-used Lencapavir becomes outside of specific markets.

Insurance for a bit seemed fine with covering Descovy but it seems that is less of a case now since it’s so much more. I would expect the same with a shot like this.

However I would hope that the added benefit of not needing to worry about adhering to taking it every day could outweigh that financial cost for insurance.

I recently switched insurance companies and my new one covers Truvada completely, not even a copay. It’s honestly kinda wild I pay more for my Adderall than I do prep. Obviously I don’t know for sure but I have wondered if it is related to it being preventative and the potential alternative cost makes it smarter to remove any barriers.

EDIT: I was mistaken, this only applies in California.

Well kinda irrelevant. My previous insurance loved to deny things, it’s why my company changed.

I worked with my doctor, tried multiple times to get them to cover Descovy (I struggled with the larger pills, I finally just forced myself to get used to it) and was never successful. Just gave up.

They are required to cover PrEP, but that doesn't mean that they are required to cover Descovy specifically. If they cover Truvada and all associated labwork or outpatient visits without any out-of-pocket costs for you, that's sufficient to comply with the law.

> This doesn't stop health insurance companies from trying to deny you, of course. You have to appeal the denial all the way up to your state's department for health insurance, which you will definitely win.

Having helped many people who've been in this exact situation, it's unfortunately not a given that you will win (you have to play your cards exactly right), and most people who need it can't afford to pay over $2000/month for the several months it takes for this to happen[0].

The most likely scenario is that the insurance company wins, because you give up.

[0] The insurance company has something like 30 days to respond for the first appeal, then an additional 45 for the second and third rounds, and that's assuming everything happens on schedule and you respond to everything immediately.

And if not, maybe there should be. I saw some ugly shit in my days working for a company that wrote software for some of the bigger insurers.

Hmm.

Truvada has been generic for about six years now.

> I recently switched insurance companies and my new one covers Truvada completely, not even a copay. It’s honestly kinda wild I pay more for my Adderall than I do prep.

That's because under the ACA, insurance companies are legally required to cover PrEP at no out-of-pocket cost, without any cost-sharing, copays, or deductibles applied. This also applies to associated labwork and outpatient office visits.

Unfortunately, many insurance companies ignore this requirement, and it's very difficult as an individual to get them to comply.

Cost comes down over time, and more testing occurs over time, somewhat by definition.

So… what specifically is debatable about the longer term?

Truvada has been around for over twenty years, and generic for 4-5 years. It still costs $2000/month list price.

More testing doesn't just magically happen either. Gilead has chosen for years not to pursue testing, let alone approval, for Descovy in various groups excluded from the original clinical trials. They've decided it's not profitable enough for them. The same could very easily happen with lencapavir, and in fact there's good reason to suspect it will.

I'm not entirely sure what the argument is, though - is it just the cynical argument of "well, these companies don't care about solving problems, just profit, so they're never going to do anything with it"? If so, then at least I understand your argument, even if I don't necessarily agree.

But I tend to be an optimist.