The news that the U.S. Food and Drug Administration this week approved the use of Truvada, an AIDS drug, to prevent infections in people who are HIV-negative is being greeted with skepticism, derision and even worry by some doctors in South Africa.
South Africa has the largest HIV epidemic in the world, with 5.6 million people infected. Each year hundreds of thousands more South Africans get the virus, so it might seem that a tool to stop new infections would be welcome here.
But there's concern that there could be serious negative consequences if Truvada starts being used as an HIV prevention pill. Truvada currently is part of the primary drug regimen in South Africa to treat HIV. Doctors here say Truvada has far fewer side effects than most other AIDS drugs but it still has some.
Dr. Ashraf Grimwood, a longtime AIDS activist based in Cape Town and now the head of Kheth'lmpilo, says he's already seeing decreased kidney function among some HIV-positive patients who take Truvada.
He says it's unclear what the long-term effect would be of putting healthy people on Truvada, but he worries that it could cause more kidney failure.
"We only have 4,000 places (in South Africa) for renal dialysis and every week people are sent home to die because we don't have kidneys to replace them," he says.
Grimwood adds that he likes the idea of a prevention pill, but he doesn't think it should be Truvada. "We simply don't know enough," he says.
There's also concern that if HIV-negative people go on Truvada, don't take it properly and get infected, new drug-resistant strains of HIV could develop. This would undermine the current national drug treatment program, which uses Truvada as a major part of its arsenal.
Dr. William Mmbara at the Ithembalabantu Clinic just outside of Durban says he's already seeing osteoporosis developing in some HIV patients who are on Truvada. "So am I going to risk giving someone osteoporosis later in life to protect them from HIV today?" Mmbara asks. "No. It just doesn't make sense."
Dr. Eric Goemaere with Doctors Without Borders in Cape Town also questions whether using Truvada to prevent HIV makes sense at a time when South Africa is still struggling to get anti-retroviral drugs to people in his words "in desperate need" of them. According to the government's own statistics, only about half the people who currently require anti-retroviral drug therapy are getting it.
"It raises a very acute ethical question," he says.
But Goemare says Truvada for HIV prevention might be appropriate for women who are trying to get pregnant.
"As we all know in Africa a young woman needs to get pregnant, needs to show her fertility. It's part of the culture," he says. "What do you do if you're not in a stable relationship? And unfortunately in the townships stable relationships are rare. So how do you get pregnant and not get infected. Actually they probably would be the first group to benefit from this if the government offered it."