The World Health Organization’s new recommendation that men who have sex with men should consider taking preventive medicine to help avoid HIV infection has renewed debate in the global health community about the best way to combat the disease.
In a set of guidelines on HIV treatment, care and prevention released this month, the WHO announced for the first time that among men who have sex with men, PrEP – short for pre-exposure prophylaxis – “is recommended as an additional HIV prevention choice within a comprehensive HIV prevention package.” Such a package should include monthly HIV testing, counseling and condom use, according to the report, published just ahead of the 20th International AIDS Conference, which started July 20 in Melbourne.
The announcement met a mixed response, with some AIDS experts and advocates saying that the recommendation is a step forward in HIV prevention strategies. Critics argued, however, that encouraging the use of PrEP could result in a drop in condom use and reverse existing prevention and treatment efforts.
PrEP involves the regular intake of a pill containing the drugs tenofovir and emtricitabine (TDF/FTC), both already used to treat HIV infection. The pill, marketed as Truvada, acts as a barrier against infection, preventing the virus from taking permanent hold in case of exposure. When taken consistently, it could cut the risk of HIV infection by more than 90 percent, according to the Centers for Disease Control and Prevention.
“Anyone at risk for HIV should consider PrEP for additional prevention,” said Mitchell Warren, executive director of the international nonprofit AIDS Vaccine Advocacy Coalition (AVAC).
When taken daily and combined with other prevention methods, PrEP is a powerful tool in efforts against HIV, Warren said.
Other experts who support the new recommendations also touted the need to inform the public about their prevention options, including PrEP.
“There needs to be much more aggressive public education about how and why PrEP should be used,” said Carl Sciortino, executive director of the AIDS Action Committee of Massachusetts (AAC), a nonprofit based in Boston. “It helps organizations [like ours] to educate the community, and it helps individuals make informed decisions.”
Still even PrEP proponents have concerns about the preventative medicine. Because the WHO’s recommendation is restricted to men who have sex with men, Warren said, it could unintentionally boost the perception that PrEP is only for gay men. That concept could curb PrEP’s future impact on other populations, such as heterosexual women in developing regions who remain at high risk for the disease, he added.
Then there are those who outright oppose the WHO recommendation.
Michael Weinstein, president of the Los Angeles-based advocacy group AIDS Healthcare Foundation told National Public Radio: "If people are taking this medication, they're definitely not going to use condoms. And if they're not taking it regularly, they're not going to be protected when they think they are. We would have many, many more infections in this country – particularly among men who have sex with men – if no one was using condoms. And we can do harm by telling people that you can pop this pill."
The medical community doesn’t know enough about Truvada to be “raving so uncritically and warning so little,” wrote Larry Kramer, a gay rights advocate and playwright who is living with HIV, in a column for The New York Times.
The debate surrounding PrEP is an extension of discussions among advocates and the medical community about the best ways to tackle HIV – and whether the time, resources and cash going into the HIV/AIDS effort should focus on prevention or on treatment.
By the end of last year, about 13 million people were on antiretroviral therapy (ART), the most common treatment method for the disease, according to the WHO. AIDS-related deaths around the world dropped by 30 percent between 2005 and 2012, based on the latest UNAIDS report.
But prevention efforts continue to lag especially for what the WHO calls key – or high-risk – populations: Men who have sex with men, people in prison, people who inject drugs, sex workers and transgender individuals. These same populations and their partners make up a big chunk of new HIV infections. For instance, prevalence among people who inject drugs is 22 times higher among non-syringe users, according to the Foundation for AIDS Research. In low- and middle-income countries, men who have sex with men are 19 times and female sex workers are almost 14 times more likely to have HIV than the rest of the population.
Yet only 70 percent of countries surveyed for the WHO’s new guidelines have programs in place that cater to the needs of men who have sex with men and sex workers. The figure drops to 40 percent for people who inject drugs. Transgender people are almost never mentioned in HIV strategies, according to the health organization.
More than 2 million people are still newly infected every year, the WHO estimates.
Scaling up efforts to prevent and treat HIV/AIDS in key populations is an essential issue at the 2014 International AIDS Conference, which has pushed forward with its agenda despite the death of at least six delegates in the fatal crash of Malaysia Airlines Flight MH17 late last week.
This year's theme is “Stepping Up the Pace." There needs to be “more effective and intensive interventions in 'hotspots' where Key Affected Populations (KAPs) are being left behind," according to the official conference website. "There is the need to involve KAPs and address the stigma and discrimination which they face, including punitive government policies."
Advocates such as AVAC’s Warren say that to stem the epidemic, the focus should be on expanding options and combining strategies for both treatment and prevention – including PrEP.
“We can’t treat our way out. We also can’t prevent our way out. No one of those interventions alone is enough,” he said.
“Until there is a vaccine or a cure,” AAC’s Sciortino added, “we continue to have a public health obligation to promoting education and access to care, treatment, and prevention, including PrEP.”
For some, however, the discussion itself is an added benefit of the WHO’s announcement: The more people talk about HIV, the better it is for efforts to fight the disease, Renato Barucco, head of the Transgender Family Program at Community Healthcare Network, wrote for The New York Times. It’s a call for action to keep educating the public, he said in the article.
“PrEP generates debates that allow people to gather information, learn about HIV, consider possibilities and reflect on the complexity of human sexuality,” Barucco wrote. “I welcome PrEP.”
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