I am not against PrEP. But I am against its domination of today’s HIV prevention discourse. We have huge barriers to address, and putting all of our eggs in the PrEP baskets may allow us to circumvent some of them, but without social, structural, and behavioral intervention, it will not create the real change that needs to happen in communities around the globe to address this epidemic and future ones.
A great deal of attention has been paid in past years and, indeed in 2012, to Pre-Exposure Prophylaxis (PrEP). It has been studied, found to be highly effective (when taken on time and (almost) all the time). The Food and Drug Administration has given its stamp of approval and last week's International AIDS Conference was a "PrEP Rally" of sorts (a term shared with me at the conference by a colleague in Boston). And off we go, doling it out to "at risk" gay men. But with all the hoopla, I can't help but take a step back and highlight the ways in which this new and, unarguably, promising new strategy scares the hell out of me.
An important preface is warranted here: I truly believe that all options should be on the table when it comes to the fight against HIV/AIDS. We are 30 years into the epidemic and it is still of the utmost importance that all possible ways to curb the spread of this virus be developed and made available. For me, the very development of biomedical prevention methods is not at all the problem. I am in no way advocating against PrEP, generally.
Now that I got that out of the way...
As a Black gay man, I have MAJOR concerns about PrEP. It should be noted that none of these concerns are related to its effectiveness (if used properly). My concerns are largely social, structural, and behavioral, and are rooted in the fact that the communities I care most about could be left out or, even worse, harmed in this new endeavor.
First, in places like the US, where there is rampant inequality and not all gay men have equal access to information, let alone medication, I fear that this will be one more intervention that will favor middle- to upper-class, mostly White gay men, and leave out the poor, folks of color, and those living in communities where even being tested for HIV is highly stigmatized.
Data suggest that HIV positive Black men who have sex with men (MSM) are 60 percent less likely to begin anti-retroviral treatment, and less likely to adhere to their medications (Millett, et.al. 2012, The Lancet). Why then should we believe that Black MSM who are HIV negative will somehow overcome all the same barriers to take a pill EVERYDAY while, for them, non-adherence has far fewer immediate consequences?
Taking such an intense medication only makes sense to me if you believe that the possible side effects outweigh the possible consequences of not taking it. In the case of someone who is HIV-positive, the potential consequences of non-adherence are obvious. For negative men, these potential side effects seem to outweigh the benefits, from my perspective. Further, Truvada hasn't been around long enough for us to know what the long-term side effects are. What will happen to our bodies 20, 30, or more years from now as a result of taking a highly potent ART for an indefinite amount of time?
Then there's the question of how it will affect risk. There are data on this and there will, undoubtedly be more. But, how do we truly measure to what level risk compensation might occur. Anecdotally, I have heard men talk about PrEP as something that will protect you and allow you to no longer worry about HIV. I have no proof that this will happen but it is absolutely a concern I have.
Finally, another recent Lancet article by Sullivan, et.al, highlights some failures of prevention interventions targeting gay men. I would posit that the reason, in large part, other interventions have failed is because we fail to address the larger issues that we are all aware of--poverty, racism, sexism, homophobia, HIV-stigma, inequality, food insecurity, housing instability, and so on. Behavior change does not happen in a vacuum. We cannot expect to be able to give folks information, condoms, and lube, and expect that they will magically get it and just "behave." Until we take away the necessity that some face to exchange sex for money, drugs, and/or housing; until we address the oppressive HIV-stigma that still exists in many communities; and until we make sure that people have food to eat, a roof over their heads, health insurance, and access to healthcare to keep them healthy, we shouldn't expect behavioral interventions to be successful for all.
To drive home the point, let me stick with Black MSM, a population with very high prevalence and incidence. In the aforementioned Lancet article by Millet, et.al, the salient disparities between black MSM and other MSM line up perfectly with the social problems I mention. Black MSM were more likely to: have a current STI diagnosis; undiagnosed HIV infection; low CD4 counts; lack access to HIV treatments; and lower adherence to treatment. All of these point to other disparities highlighted in the paper -- lower income, less education, higher rates of incarceration, greater unemployment, and less access to health insurance. Now, I ask you -- How can we expect for prevention interventions to be effective in such climates? And to my original point -- How will the implementation of PrEP even begin to overcome these barriers?
I will be happy is all of my fears and concerns are never validated. If we are able to curb this epidemic with biomedical intervention, such as PrEP, I will lead the parade to celebrate. But I am not holding my breath yet. To reiterate, I am not against PrEP. But I am against its domination of today's HIV prevention discourse. We have huge barriers to address, and putting all of our eggs in the PrEP baskets may allow us to circumvent some of them, but without social, structural, and behavioral intervention, it will not create the real change that needs to happen in communities around the globe to address this epidemic and future ones.