BREAKING NEWS: Fed Change Signals Huge Shift in How We Prevent HIV

  • metta

    Posts: 39165

    May 15, 2014 4:47 PM GMT
    BREAKING NEWS: Fed Change Signals Huge Shift in How We Prevent HIV

    New health guidelines urge a massive increase in number of gay men, and other risk groups, taking the one-a-day PrEP pill, Truvada

    "A C.D.C survey last November showed that the number of gay men reporting unprotected sex had risen nearly 20 percent from 2005 to 2011. Given the stigma around admitting to unprotected sex, that figure is probably much higher. Now, the hope is that by encouraging gay men who have unprotected sex to take Truvada, the number of new infections will continue to fall as scientists continue to hunt for a cure."

    http://www.hivplusmag.com/prevention/2014/05/15/breaking-news-fed-change-signals-huge-shift-how-we-prevent-hiv
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    May 15, 2014 6:05 PM GMT
    Waiting for Art Deco to charge in and say that this is another "green light" to bareback.

    If he doesn't then it's a purely a bias against people with HIV.

  • metta

    Posts: 39165

    May 15, 2014 6:10 PM GMT
    Truvada Side Effects from the Truvada web site

    http://www.truvada.com/truvada-side-effects


    The most common side effects of TRUVADA are:

    In people taking TRUVADA with other HIV-1 medicines to treat HIV-1 infection, common side effects include: diarrhea, nausea, tiredness, headache, dizziness, depression, problems sleeping, abnormal dreams, and rash.

    In people taking TRUVADA to reduce the risk of getting HIV-1 infection, common side effects include: headache, stomach-area (abdomen) pain, and decreased weight.



    Serious side effects of TRUVADA may also include:

    New or worsening kidney problems, including kidney failure. Your healthcare provider may do blood tests to check your kidneys before and during treatment with TRUVADA. If you develop kidney problems, your healthcare provider may tell you to take TRUVADA less often, or to stop taking TRUVADA.

    Bone problems, including bone pain or bones getting soft or thin, which may lead to fractures. Your healthcare provider may do tests to check your bones.

    Changes in body fat can happen in people taking HIV-1 medicines.

    Changes in your immune system. If you have HIV-1 infection and start taking HIV-1 medicines, your immune system may get stronger and begin to fight infections. This may cause minor symptoms such as fever, but can also lead to serious problems. Tell your healthcare provider if you have any new symptoms after you start taking TRUVADA.



    TRUVADA can cause serious side effects:

    Too much lactic acid in your blood (lactic acidosis), which is a serious medical emergency. Symptoms of lactic acidosis include weakness or being more tired than usual, unusual muscle pain, being short of breath or fast breathing, nausea, vomiting, stomach-area pain, cold or blue hands and feet, feeling dizzy or lightheaded, and/or fast or abnormal heartbeats.

    Serious liver problems. Your liver may become large and tender, and you may develop fat in your liver. Symptoms of liver problems include your skin or the white part of your eyes turns yellow, dark “tea-colored” urine, light-colored stools, loss of appetite for several days or longer, nausea, and/or stomach-area pain.

    You may be more likely to get lactic acidosis or serious liver problems if you are female, very overweight (obese), or have been taking TRUVADA for a long time. In some cases, these serious conditions have led to death. Call your healthcare provider right away if you have any symptoms of these conditions.

    Worsening of hepatitis B (HBV) infection. If you also have HBV and take TRUVADA, your hepatitis may become worse if you stop taking TRUVADA. Do not stop taking TRUVADA without first talking to your healthcare provider. If your healthcare provider tells you to stop taking TRUVADA, they will need to watch you closely for several months to monitor your health. TRUVADA is not approved for the treatment of HBV.
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    May 15, 2014 6:23 PM GMT
    Side Effects of not taking Truvada: 50 thousand cases of HIV every year.

    They don't give a frequency or percentage of the side effects. In the NYT article: "Truvada, a mix of tenofovir and emtricitabine, is considered relatively safe with few side effects. Generic versions are made in India, and it has become the backbone of AIDS treatment in poor countries."
    http://www.nytimes.com/2014/05/15/health/advocating-pill-us-signals-shift-to-prevent-aids.html?_r=0

    Not every negative person needs to take it. Those in a strictly monogamous relationship for example (both Negative or Magnetic couple NEG and HIV+/U).

    Some won't for the reasons above. Talk to your doctor to see if you are a good candidate, health wise. Some won't because of the expense. But insurance should cover it and there are assistance programs.

    Here's that damn Dr. Fauci, yet again....proving my "Agenda"!!!!
    “Making the perfect the enemy of the good is something we’ve got to get over,” said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases and the country’s best-known AIDS doctor. “I strongly support the C.D.C. doing this.”
  • musclefun8

    Posts: 39

    May 19, 2014 4:40 PM GMT
    I've been on PrEP for 6 months without any side effects. This is a great thing!!! Protect yourself. Why the negativity?
  • metta

    Posts: 39165

    May 19, 2014 5:17 PM GMT
    ^
    I don't see trying to be informed as being negative. I think that it is important to look at the side effects before taking anything.
  • metta

    Posts: 39165

    May 19, 2014 5:19 PM GMT
    unckabasa said Side Effects of not taking Truvada: 50 thousand cases of HIV every year.

    They don't give a frequency or percentage of the side effects. In the NYT article: "Truvada, a mix of tenofovir and emtricitabine, is considered relatively safe with few side effects. Generic versions are made in India, and it has become the backbone of AIDS treatment in poor countries."
    http://www.nytimes.com/2014/05/15/health/advocating-pill-us-signals-shift-to-prevent-aids.html

    Not every negative person needs to take it. Those in a strictly monogamous relationship for example (both Negative or Magnetic couple NEG and HIV+/U).



    What does the 'U' stand for?
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    May 19, 2014 5:21 PM GMT
    metta8 said
    unckabasa said Side Effects of not taking Truvada: 50 thousand cases of HIV every year.

    They don't give a frequency or percentage of the side effects. In the NYT article: "Truvada, a mix of tenofovir and emtricitabine, is considered relatively safe with few side effects. Generic versions are made in India, and it has become the backbone of AIDS treatment in poor countries."
    http://www.nytimes.com/2014/05/15/health/advocating-pill-us-signals-shift-to-prevent-aids.html

    Not every negative person needs to take it. Those in a strictly monogamous relationship for example (both Negative or Magnetic couple NEG and HIV+/U).



    What does the 'U' stand for?


    Undetectable.
  • metta

    Posts: 39165

    May 19, 2014 5:39 PM GMT
    ^
    Thanks! I have a few dumb questions about people that are undetectable.

    When someone is undetectable, how stable is that over time? Can that fluctuate?

    As long as they stay on their medicine, is it stable enough to say that they will continue to be undetectable?

    If someones immune system is down...because they are sick with the flu, or cold, or something else, could that affect them being undetectable?

    If they miss their meds for a period of time, a day, a week, a month...will they still be undetectable?
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    May 19, 2014 6:43 PM GMT
    metta8 said^
    Thanks! I have a few dumb questions about people that are undetectable.

    When someone is undetectable, how stable is that over time? Can that fluctuate?

    As long as they stay on their medicine, is it stable enough to say that they will continue to be undetectable?

    If someones immune system is down...because they are sick with the flu, or cold, or something else, could that affect them being undetectable?

    If they miss their meds for a period of time, a day, a week, a month...will they still be undetectable?


    Not dumb at all!

    I can only speak from my own experience:

    Online I've seen warnings of "spikes" but in 10+ years, being tested ever 3 to 4 months I've never become detectable again after my initial viral load was suppressed. If there were spikes they were still too low to measure. And I've had a cold a few times when tested I know.

    A DRUG HOLIDAY (going off meds because they are tired of it) is never a good idea! My ex did that for a year. I pleaded with him to stop that nonsense. He didn't get sick, at least not HIV related, but his numbers dropped and he was VERY detectable, 70,000 copies....undetectable is 40 (or 50?) or less. It took 12 months to get his under control/suppressed to undetectable again. His T-cells are 170 (OK).....mine are 1000+ (excellent!).

    I was on a cruise a couple of years ago, and ran out of the 2X a day meds, packed for 1X duh!. So I missed 3 days. It was excruciating as I'm very consistent. I was tested shortly thereafter and nothing had changed. I seldom miss a dose. At the UCSD HNRC study we determined a 99+ consistency. Meth users are notoriously and habitually forgetting to take them.....NOT good. So it's less effective over a long term (IMHO), if you miss 3 this week and 2 next week, and that's normal for a person on drugs or impaired they will "spike" if not stay detectable. They MAY even develop a drug resistance.
  • metta

    Posts: 39165

    May 19, 2014 11:15 PM GMT
    Thanks for the replies. I have been wondering about this for a while.
  • slimnmuscly

    Posts: 541

    May 20, 2014 3:08 AM GMT
    I hope this step by the CDC helps counter some of the seriously misguided thinking around Truvada (e.g., guys avoiding guys on the pill because they assume they must be poz). While it doesn't protect against other STIs, neither, frankly, does having oral sex without a condom, and at least guys on Truvada have to get tested every three months (not sure if that includes testing for other STIs, though). If enough poz guys get their viral loads undetectable and enough "at-risk" negative guys go on the pill, it could tip the epidemic in the right direction.

    With that said, gay men still need to adjust their thinking about what constitutes safe sex to account for the rise in syphilis and drug-resistant strains of gonorrhea, and the impact high STI rates have on the proverbial sexual ecology. Those diseases were once thought to be on the verge of elimination, which should give us pause about pinning too many hopes on the little blue pill.
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    May 20, 2014 3:49 PM GMT
    unckabasa said Side Effects of not taking Truvada: 50 thousand cases of HIV every year.



    Plain and simple: people who are already poz need to stop spreading HIV. We've known since the 80's how to stop HIV in its tracks. There's no reason why in 2014 twenty percent of adult gay men should be HIV+. HIV rates weren't even that high twenty years ago. Truvada has some horrific side effects which may not even be apparent for some time. You should not be depending on a pill to keep yourself HIV free. Condoms are cheap and people don't want to use them. It makes no sense that an expensive pill with side effects will be any better.
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    May 20, 2014 4:43 PM GMT
    AlmondJoy said
    unckabasa said Side Effects of not taking Truvada: 50 thousand cases of HIV every year.



    Plain and simple: people who are already poz need to stop spreading HIV. We've known since the 80's how to stop HIV in its tracks. There's no reason why in 2014 twenty percent of adult gay men should be HIV+. HIV rates weren't even that high twenty years ago. Truvada has some horrific side effects which may not even be apparent for some time. You should not be depending on a pill to keep yourself HIV free. Condoms are cheap and people don't want to use them. It makes no sense that an expensive pill with side effects will be any better.


    I agree basically, but....

    Horrific? If you read the packaging on any drug there are seemingly hundreds of side effects. Seems safe for most people. *See NYT article above).
    That condoms fail is one issue. But some just don't use them for many reasons: the heat of the moment, the feel (or lack of), irritation....whatever.

    It's been 30 years and there's a constant that needs to be addressed. Some people just refuse to use them.

    “Making the perfect the enemy of the good is something we’ve got to get over,” said Dr. Anthony S. Fauci

    You say:
    "people who are already poz need to stop spreading HIV."

    That makes perfect sense, but it's terribly naive. It's the people who don't know they are POZ who are spreading mostly now. The "I'm Negative as of 12/03/13 DDF" guys. Or worse, don't get tested at all for fear of the stigma, laws, etc.
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    May 20, 2014 11:37 PM GMT
    Gilead (make of Truvada) primarily supports Republicans:

    Rep. House Majority 2012 $7,500
    Rep. Senate Majority 2012 $7,500
    Dem. Senate Majority 2012 $2,500
    Dem. House Majority 2012 $2,500
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    May 21, 2014 10:36 AM GMT
    mx5guynj saidGilead (make of Truvada) primarily supports Republicans:

    Rep. House Majority 2012 $7,500
    Rep. Senate Majority 2012 $7,500
    Dem. Senate Majority 2012 $2,500
    Dem. House Majority 2012 $2,500



    Seems like peanuts in the scheme of things. It sounds counter intuitive considering who their market is. But with National Health I can see where they wouldn't be favoring Democrats. They probably could have made more $$$ with a Republican Plan.
  • RunnerMD

    Posts: 157

    May 21, 2014 1:22 PM GMT
    It's important to use a condom to protect against STIs, including HIV. If you know you are going to have slip ups now and again, or if you want to have an added line of defense then take PrEP as well. I think it's as simple as that, really.

    The fact that the rate of condom use over the last few years has dropped is incredibly disappointing. Let's hope that trend reverses itself because PrEP isn't going to protect a person from the non-HIV diseases that are running through the community as well.
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    May 21, 2014 3:55 PM GMT
    musclefun8 saidI've been on PrEP for 6 months without any side effects. This is a great thing!!! Protect yourself. Why the negativity?


    Do you also use condoms?
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    May 21, 2014 5:29 PM GMT
    MuchMoreThanMuscle said

    Plain and simple: People who are HIV- need to make sure they remain HIV- by playing safe and using condoms or simply abstaining from sex altogether. It takes two people for an HIV infection to pass from one person to another. There's no need to blame or vilify one person while the other person gets to hold onto innocent victim status.

    Uselessly, you bring up some statistics about gay men with HIV yet you fail to acknowledge the demographics regarding HIV on a global level. In other parts of the world such as in Africa, HIV is predominately a concern within the heterosexual community.

    You also fail to recognize that HIV is a large concern within the American heterosexual black community but you focus your disdainful comments toward the gay community only.

    You are, by far, not the voice of reason nor are you an authority on the matter in any way, shape or form. Do yourself a favor and wipe the egg off your face and cease all pontifications regarding the sexual behavior of others.


    HIV in Africa is the result of dry sex. You can't equate what's going on in Africa to any other place in the world. If dry sex was practiced everywhere else in the world, HIV/AIDS would have similar catastrophic rates of infection.

    http://en.wikipedia.org/wiki/Dry_sex

    I have been following and have educated myself on HIV/AIDS for the past three decades, ever since I saw gay men on tv with Kaposi's sarcoma, and the doctors were referring to it as incurable gay cancer.

    Twenty percent of adult gay men are HIV+ in 2014. Twenty percent of straight people are not. Twenty percent of lesbians are not. It's not rocket science what's going on: you get it, you pass it to the next guy or guys, who passes it on to the next guy or guys. How many more must be infected? How many more must die?

    My observations have been when you have these bowel fetishes, rather than them diminishing when you test poz, they strengthen due to the fact that you don't have to worry about testing poz ever again. What joy could there be in getting or giving HIV?

    The Gay HIV Epidemic Is Increasing in All Nations
    http://www.aidsmeds.com/articles/MSM_global_1667_24845.shtml

    New And More Aggressive HIV Strain Causes AIDS Faster
    http://www.businessinsider.com/hiv-strain-faster-aids-2013-11

    Whatever Happened to AIDS and Straight Men?
    http://www.aliveandwell.org/html/risk_realities/whatever_happened.html
  • AMoonHawk

    Posts: 11406

    May 21, 2014 5:50 PM GMT
    How much does it cost?

    compared to say .... condoms?

    Can you just take it one night when you are going to have sex then skip it if you are not?
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    May 21, 2014 7:49 PM GMT
    AMoonHawk saidHow much does it cost?

    compared to say .... condoms?

    Can you just take it one night when you are going to have sex then skip it if you are not?


    Costs: depends on your prescription coverage. If I was taking it: $20 monthly copay, $1500/month paid by insurance. If you have a prescription deductible, that would make it more expensive. Where I work, the organization is self-insured, so my work is on the hook for the remainder of the cost.

    And you need to take it everyday.

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    May 21, 2014 10:22 PM GMT
    MuchMoreThanMuscle said
    Don't come at me with this malarkey regarding dry sex. I read the link that you provided me and it only states that this is practiced in isolated areas of Africa. It does not mention South Africa at all which is one of the major areas where HIV is growing rapidly and women are the predominantly effected gender. It also provides no explanation for how heterosexual communities in America are becoming HIV+.

    Regardless of this dry sex bullshit, these people (namely men) are still refusing to wear condoms which is what I thought you were promoting in the first place. Now, it's like you're excusing them.

    You're obsessed with shaming people, namely gay men, for behavior that is natural. Guess what? That approach doesn't and has not worked. It creates more polarity and resistance which compounds the situation.

    You're a facelss, self loathing gay coward of a man who boldly asserts his condemnation behind the safety of anonymity and a keyboard. Luckily for the rest of us no one will ever heed your tedious talk.

    Why do you even ca yourself "Almond Joy" anyway? There's no joy in you at all. Oh and that article on AIDS and straight men waz reprinted from 2004 so that's at the very least a ten year old online article and its credibility is dubious. Do yourself and mainly us a favor; stick to current, unbiased, non-propagandistic, neutral and reliable sources like the CDC and the WHO for current stats on HIV.

    That article is flat out wrong. More people died due to diabetes related illness compared to people today who died of complications from AIDS. In America, anyway. Maybe when that article was written more than ten years ago it was true. But today it is no longer the case. And there is a discussion about that in the threads which you can find and read. You are promoting outdated information as true. I see no credibility in what you tout in the threads.


    I'm not shaming anyone but apparently that's how you take it. I'm just giving the facts. If you've followed HIV/AIDS for 30 years you may have a different perspective. It's obvious what's happened. What you consider natural and what I consider natural are two different animals, as are what you consider self loathing or not. Your lifestyle isn't my lifestyle. Despite that article being written in 2004 it's valid. In three decades of HIV/AIDS there still hasn't been a straight AIDS pandemic other than parts of Africa. Some straight people, mainly in Africa, use anal sex as a birth control method, and look at the price the women have paid, and the children they give birth to.

    Are 20% of straight people in the US or Canada HIV poz? No
    Are 20% of straight people in France or England HIV poz? No
    Are 20% of straight people in China or India HIV poz? No
    Do you know why? You can argue with biology and science all you want but you won't win.

    http://www.aliveandwell.org/html/risk_realities/whatever_happened.html

    "The question of what triggers an HIV infection to become AIDS is controversial. What is known is that at some point, the virus replicates by taking over the T4 cells, doubling its numbers every 12 hours. Eventually, such work in the service of its enemy exhausts the T4 cell and it dies like an overworked motor. With its T cells devastated, the immune system breaks down, leaving the body vulnerable to the opportunistic cancers and infections that typify AIDS. One such cancer, Kaposi’s sarcoma, ravages such internal organs as the lymph nodes, brain, lungs, and digestive tract.

    But if HIV can’t reach the lymphocytes, there’s no infection. This is why it’s so hard to contract the virus through old-fashioned vaginal sex. The vagina is a rugged structure, built to withstand everything from a thrusting penis to the passage a baby's head during childbirth. Its walls are muscular, covered by a thick layer of epithelial cells that resist tearing and that secrete a lubricating mucus that contains enzymes for fighting off bacteria. Its blood vessels run well below the surface, barring HIV from direct contact with the blood and thus from the lymphocytes

    “The vagina is an organ that is essentially designed to prevent abrasion,” says Robert Root-Bernstein, a professor of physiology at Michigan State University and recipient of a MacArthur Genius Fellowship. “The blood vessels are buried quite deep, so there are no lymph nodes present. It's very difficult to get anything vaginally into the blood.”

    The rectum, on the other hand, offers almost no protection. It is lined with extremely thin tissue, no thinner than a lambskin condom, and can easily tear. It is part of the lower intestine, which has evolved to perform one major task—uptake nutrients and water from your bowels into your circulatory system—and so it is intertwined with capillaries. To keep out the bacteria that thrive in the colon, half your immune system surrounds your gut in the form of lymph nodes whose sole job it is to monitor the water and nutrients re-entering the body.

    The rectum has no mucus-secreting cells to help ease the passage of a penis. The subsequent tearing in the cell walls (which lubricants do little to prevent) offers HIV-carrying ejaculate easy access to lymphocytes that cluster just beneath the surface. From there HIV enters the bloodstream. Dildos, sometimes used before such penetration, do further damage and increase the likelihood of transmission, as do hemorrhoids. A constant hazard of anal sex, hemorrhoids can rupture and bleed, providing the virus with another gateway the bloodstream. Semen also has enzymes that help it bore through these cell walls, even in the absence of tearing. (Anal intercourse is far less risky for the active partner)"

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    May 22, 2014 12:16 AM GMT
    MuchMoreThanMuscle saidNow I'm wondering if you're even gay. Please stop wasting internet space by providing us your theories on vaginal and anal sex and which one is riskier.


    They're not my theories. It's obvious.

    MuchMoreThanMuscle saidYou attacked me in a thread about syphilis which was completely unsolicited and you were way off base. You're all about shaming and judging sexual behavior.


    Oh, please! icon_rolleyes.gif If you keep going for STD tests you're either paranoid or unsure who your sex partners are.

    MuchMoreThanMuscle saidJust because you follow HIV for three decades doesn't mean you're an expert. The only people who succumb to full blown AIDS are those from impoverished areas such as Africa. And this is due to lack of modern medical care.


    Never said I was an expert.

    MuchMoreThanMuscle saidToday in the US, less than 1% of people with HIV succumb to AIDS and die. You're promoting old outdated information. And the growing demographic of people in America who are becoming HIV+ are teenagers irrespective of sexual orientation. Go to the CDC website and learn current stats.


    They're mostly gay. You must be living under a rock.

    HIV Among Youth

    Fast Facts

    Youth aged 13 to 24 accounted for an estimated 26% of all new HIV infections in the United States in 2010.

    Most new HIV infections among youth occur among gay and bisexual males; there was a 22% increase in estimated new infections in this group from 2008 to 2010.

    Almost 60% of youth with HIV in the United States do not know they are infected.

    Youth in the United States account for a substantial number of HIV infections. Gay, bisexual, and other men who have sex with men* account for most new infections in the age group 13 to 24; black/African American** or Hispanic/Latino gay and bisexual men are especially affected. Continual HIV prevention outreach and education efforts, including programs on abstinence, delaying the initiation of sex, and negotiating safer sex for the spectrum of sexuality among youth—homosexual, bisexual, heterosexual, and transgender—are urgently needed for a new generation at risk.

    New HIV Infections Among Youth (Aged 13–24 Years)

    In 2010, youth made up 17% of the US population, but accounted for an estimated 26% (12,200) of all new HIV infections (47,500) in the United States.

    In 2010, young gay and bisexual men accounted for an estimated 19% (8,800) of all new HIV infections in the United States and 72% of new HIV infections among youth. These young men were the only age group that showed a significant increase in estimated new infections—22% from 2008 (7,200) through 2010 (8,800).

    In 2010, black youth accounted for an estimated 57% (7,000) of all new HIV infections among youth in the United States, followed by Hispanic/Latino (20%, 2,390) and white (20%, 2,380) youth.

    HIV and AIDS Diagnoses and Deaths Among Youth (Aged 13-24)

    An estimated 10,456 youth were diagnosed with HIV infection in the United States and six dependent areas in 2011, representing 21% of an estimated 50,199 people diagnosed during that year. Seventy-eight percent (8,140) of these diagnoses occurred in those aged 20 to 24, the highest number and population rate of HIV diagnoses of any age group (36.3 new HIV diagnoses/100,000 people).

    By the end of 2010, of the estimated 39,035 youth living with diagnosed HIV infection in the United States and 6 dependent areas: An estimated 27,621 HIV diagnoses were among young men. Of these, 77% of HIV diagnoses were attributed to male-to-male sexual contact and 13% to perinatal exposure.

    An estimated 11,413 HIV diagnoses were among young women. Of these, 56% were attributed to heterosexual contact and 34% to perinatal exposure.

    In 2011, an estimated 3,004 youth in the United States and six dependent areas were diagnosed with AIDS, a number that has increased 29% since 2008.

    By the end of 2010, an estimated 11,731 youth with an AIDS diagnosis had died in the United States and six dependent areas since the HIV epidemic began.

    Page last reviewed: April 7, 2014
    Page last updated: April 7, 2014

    http://www.cdc.gov/hiv/risk/age/youth/index.html
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    May 22, 2014 4:47 AM GMT
    "Continual HIV prevention outreach and education efforts, including programs on abstinence, (really?) delaying the initiation of sex, and negotiating safer sex for the spectrum of sexuality among youth—homosexual, bisexual, heterosexual, and transgender—are urgently needed for a new generation at risk."

    And that's been the recipe for failure for 30 years. Abstinence? Is this the Reagan administration? Negotiating safer sex, wtf does that even mean? People lie....asking is virtually pointless, "negotiating" is purely stupid in the HIV framework.

    That's the point of Truvata. It deals with reality, not some silly morality that has nothing to do with real people.
  • FitGwynedd

    Posts: 1468

    May 22, 2014 6:12 PM GMT
    The kidney failure issue is fairly serious. Have they tested what the likliehood of kidney failure is after taking Truvada for 5, 10, 15 or 20 years?