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The WHO's unwise recommendation for gay men

| 7 Comments
PrEP is now being recommended by the WHO for, it seems all   sexually active gay men.  Actually it's not quite that stark - they continue to recommend condom use as well.   Despite this, many will probably see this as a recommendation to rely on PrEP as an alternative to condoms.

The WHO recommendation is a population based proposal, a public health recommendation as opposed to recommendations for specific individuals, and as such it is truly perplexing. Recommendations for individuals are different because they take into account individual circumstances, such as the extent to which a specific person is at risk.  Population based recommendations are recommendations made across the board, in the case of the WHO, addressed to all men who have sex with men.     

While assuring us that the recommendations are evidence based and providing the customary explanation of how the strength of evidence is graded, we learn that the WHO has made a sweeping worldwide population based recommendation on evidence provided by just one randomized study! This was the iPrEx study, which was beset with interpretative difficulties, not least because few took the medication as directed, if at all.  

We simply do not know enough about PrEP to make a sweeping population based recommendation.  We have little idea of what adherence might look like in various populations, we know little about the degree of protection in specific sexual acts.  Different sex acts carry different risks, for example, to the receptive or insertive partner in anal sex.   Also, how effective is PrEP  in situations of exposure to high and low viral loads. So the WHO recommendation that all sexually active gay men consider PrEP is not only remarkable in that it's supported by such scanty evidence, it's also offensive because gay men are viewed as so uniformly dangerous that they need to be medicated.  

A more balanced response would have been a call for more research, and importantly, for a fuller description of those individual situations where PrEP use may be a rational preventative intervention at the present time.    

The use of PrEP by an individual is very different.   On an individual basis PrEP use can be a completely appropriate intervention.   For example, using PrEP because of an inability to maintain an erection with a condom is absolutely appropriate, and is a very welcome intervention to enable a fuller  sexual expression in what is probably  a large number of men whose difficulty with condoms, for whatever reason stand in the way of  satisfactory  sex.  Medical supervision is also more likely in individual situations. It is important to check for HIV infection and to monitor for sexually transmitted infections and drug toxicities. Since PrEP offers no protection from the transmission of infections that might be interrupted by condoms we might expect an increase in such infections with a wide roll out of PrEP.  The current increase in sexually transmitted infections among gay men in some cities is most likely attributable to an increase in unprotected sex.    Many sexually transmitted infections facilitate the transmission of HIV which may be another factor that could drive an increase in new HIV infections.    

The way PrEP has been promoted during the past few years has surely contributed to the poor support received for prevention education.   One way in which this has happened is the shifting of budgets for prevention to those entities, private or government insurers that pay for drugs used in biomedical prevention.  

There seems to be a widespread view that prevention education does not work.  But we know that it can work. The adoption of safe sex practices including condom use in the early 1980s curbed the spread of the epidemic, although admittedly conditions are not the same today.   

If prevention education has been ineffective it may be because there has been so little of it, and what little there is has not been properly targeted.  The move of the epidemic into African American communities during the 1990s  was occurring in plain view yet the federal government was churning out expensive vacuous untargeted prevention messages in the form of "America responds to AIDS," a futile exercise that helped to discredit prevention education.      

I get the sense that some younger gay men feel they have missed out in not experiencing the abandon of the 1970s and see PrEP as a way to make up for this.  The real lesson of the 1970s is that sex with multiple different partners on such a vast scale, as occurred in NYC in the 1970s, permits any pathogen that can be transmitted sexually to disseminate widely. That's what started to happen with amebas and other intestinal parasites and HIV, and is happening with syphilis, gonorrhoea, herpes, hepatitis and many other infections.  There surely will be others beyond HIV.   

Since we really have relatively very little information about PrEP, and almost none about its use on a population level such a broad recommendation by the WHO is absolutely inappropriate, so maybe faced with increasing HIV infections among gay men, the WHO is simply giving up  and proposing an unproved intervention out of desperation.  When I say unproven, I mean it is unproven as a viable population based intervention. Looked at this way, it's a put down -  a response that may be no more than gestural to people who continue to harm themselves by refusing to use condoms in sex with partners of unknown sero status. Despite their voluminous report It's impossible to understand how the WHO came to make such a sweeping recommendation with so little evidence to support it.  

This unwise recommendation may also have the effect of increasing new HIV infections if it results in an increase in unprotected sex where adherence to the medication is inadequate.  

I hope there will be a critical look at the WHO panel and funders responsible for producing such unhelpful recommendations for men who have sex with men.

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Comments on Joseph Sonnabend, MD's blog entry "The WHO's unwise recommendation for gay men"

I agree with many things Joe says here. We DO need more research. And it's a pipe dream to assume we're going to get more than a handful of people on PrEP worldwide to start with. But there is this polarity he makes between PrEP and traditional prevention inc condoms I simply think is invalid. He says, for instance, that safer sex education still works and we shouldn't abandon it. But PrEP will require just as safer sex education as condoms: is is a variety of safer sex, and we need to get beyond the point where 'safer sex' is solely defined as condoms and their use is the sole measure of social responsibility in gay men. To take PrEP is also an act of social responsibility, of gay citizenship, as witnessed by many of the deeply thouthful testimonies I have read from people considering or starting PrEP. There is no conceivable HIV prevention intervention - even one-offs like circumcision - that won't need to be surrounded by a structure of sexual health education. PrEP is a new tool, not a substitute for helping gay men discuss status, learn about HIV, develop the ability to cultivate rewarding relationships, and pursue pleasure without getting fucked up. Of course PrEP has its own funding, adherence and resource implications as do other prevention methods. But I think it should be a kind of activist 'sin' to place methods that work in implied competition with each other. What works, works, and we need to make sure they work together. One of the things we tried to do with this - www.hivt4p.org - was to find a basic set of standards to unite behind to settle similar arguments about TasP. I would like to see something similar for PrEP.

I strongly disagree. If you want to take Truvada, do it. I do, and I'm much happier because of it.

I certainly support any individual who chooses to take Truvada PrEP. I was writing about PrEP recommendations and made the distinction between those made to individuals and those made to everyone. I did say that PrEP can be an appropriate individual choice.

I was critical of the WHO recommendations which are addressed to all men who have sex with men everywhere in the world. There is more to providing PrEP than writing a prescription. Regular tests for infection, for toxicity and for STIs or support for adherence are not uniformly available, let alone information helpful in assessing the degree of risk in individual circumstances.

It's true that the WHO stated that PrEP should be part of a comprehensive prevention package. They were dismayed when papers reported they were advising all gay men to take PrEP without qualification.

This dismay speaks to the poor quality of the recommendations. A more thoughtful panel might have taken into account that there is a common perception that PrEP is an alternative to condoms, that the advice to also use condoms is just pro forma, something that can be safely ignored. They should therefore have gone to some lengths to avoid this by emphasizing in the strongest terms that they are definitely not recommending that PrEP be used alone.

The problem with PrEP is not one of paucity of information about it, but of paucity of reliable and accurate information about it (on this point, iPrEX Ole added to what iPrEX showed 4 years ago, and 3 other trials in HSX and IDU have also demonstrated efficacy. Pharmacodynamics and kinetics favour better efficacy for gay men).

Personally, I have never been a staunch believer of PrEP as an intervention that would make a difference at population level or a supporter of a massive indiscriminate roll out. In this regard I agree with Dr Sonnabend that the WHO could have better formulated and communicated its recommendation - and the media better reported it - and many gay men better research it.

But on the other hand I believe that PrEP should by now be part of the options available to Gay men and MSM who are prepared to take it as indicated in a controlled medical environment. It should not necessarily be offered as the first choice to all gay men, but they should not be deprived of it.

I do not believe PrEP and condoms are in competition. The opposition to PrEP even among gay men clearly show that it is not the case. As we talk more and more of personalised Medicine, I think we should likewise move towards personalised HIV prevention - and this is where PrEP has a role to play.

Dr, Sonnabend was the expert in this area in the 1980s. He was right then and is likely now completely right on PrEP in it's current form.
30 years experience should teach us all something. This sounds like the last and best word on PrEP - as it is now being touted.

Like other commenters, I greatly respect Dr. Sonnabend's perspective and wise caution. I see a big source of the problem to be the huge disconnect between the ASOs and PWAs vs. the HIV negative. I feel the HIV crowd including its leadership pushes a pro-barebacking and pro-sero discordant dating agenda. This petrifies HIV negative guys, but since it's not socially acceptable to admit this, everything is swept under the rug. I think PREP is a good choice for HIV-waiting to happen guys who test positive for other STDs. Once the high risk guys are prescribed PREP, the challenge I see is what MDs should do with average joe gay guys-- most new HIV infections are simply dumb luck-- ie. dude thought he was neg etc.

A current huge missed opportunity is to aggressively test, treat, and retain in treatment the 50% of HIV poz people who are not being retained in care and not being virally suppressed. Probably would be a more effective strategy than large scale PREP for medium risk guys.

Dr. Sonnabend, you seem unable to accept the reality that PrEP *IS* an *alternative* to condoms for many. i note your and others' attempts to semantically dance around the issue of who is and is not a candidate. that dance has grown tiresome.

once and for all: maintaining or increasing rates of successful and consistent condom usage can only be achieved by focusing on the deficiencies of those devices in the experience of many users. simply attacking PrEP because you fear a bum's rush away from condoms is unsustainable, rear-guard and achieves nothing beyond helping to keep HIV an ever-gayer disease.

your widely quoted and disinformational Poz.com posting about "absolute risk" and PrEP remains a profound misrepresentation of the risk faced by very large groups of MSM, and the profound reduction in that risk that can be provided by adherent use of PrEP. Just as you criticize PrEP advocates for "not taking the Real World into account", so too are you guilty of same...your anti-PrEP postings are touted as the Secret Weapon of anti-PrEP trolls roving the Internet and spreading vicious hate, stigma and overt disinformation.

the net effect has been an unconscionable obfuscation of the most important new Prevention tool for HIV negative people to use since condoms. all while gay men face ever more apocalyptic infection rates.

history will not be kind to you on this. instead of improving a deficient public health strategy of condom-advocacy, you continue to focus on attacking or micro-attacking PrEP.

it would be nice if you could just start every article on this with "DISCLAIMER: I HATE CHEMOPROPHYLAXIS."

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This page contains a single entry by Joseph Sonnabend published on July 15, 2014 5:25 PM.

How to have sex in an epidemic: 30th anniversary was the previous entry in this blog.

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