In a “truly watershed period for lesbian gay bisexual and transgender rights and freedoms,” in the global north, the few prevention methods that work for men who have sex with men need to rapidly be taken to scale, particularly pre-exposure prophylaxis, Dr. Chris Beyrer writes in a new piece published in Current Opinions in Infectious Diseases.
Of all the recent advancements that have been shown to be effective in preventing HIV, daily oral pre-exposure prophylaxis (PrEP) has been shown to be the most efficacious prevention method for men who have sex with men, after condoms. The landmark iPrEx trial demonstrated 41 percent efficacy among men who have sex with men and transgender women with a regimen that includes Truvada, and although additional trials that investigated PrEP in adult men found efficacy, “this striking reality has been little remarked on, perhaps because the HIV community is so intent on finding solutions that will work for all at risk,” Beyrer writes.
He continues, “should we not be rapidly attempting to adapt, use, and scale up this effective intervention for a population for whom no other additional option is currently available?” Only the U.S. has approved the use of daily oral Truvada PrEP for men who have sex with men and others at risk, but no other country that participated in iPrEx, including Thailand, Peru, Brazil, and South Africa, has followed.
Beyrer acknowledges concerns about providing antiretroviral drugs for people without HIV infection when we have so far to go in providing ART to those already infected. “This is true, but it is also a somewhat problematic argument on public health grounds, since the failure to provide effective prevention, given the high rates of acquisition in the epidemics, virtually ensures more patients who will require treatment in the future,” Beyrer argues.
He notes that PrEP is likely to be used not for life but for periods of risk, and “knowledge of the severity of long-term complications of chronic HIV infections make risk vs. benefit assessments strongly in favor of remaining HIV negative.”
HIV infection rates are either stable or rising among gay, bisexual, and other men who have sex with men in all income settings around the world, and rates are rising fastest among the youngest men.
Beyrer writes there are a number of explanations for this phenomenon:
- Increased size and lower density of men who have sex with men sexual networks relative to other groups
- The very high per act and per partner transmission probabilities associated with anal intercourse
- The role versatility of men who have sex with men that a given man can be both an insertive and receptive partner in anal sex
In addition to that, HIV criminalization, stigma, discrimination in healthcare settings, and other structural barriers make men who have sex with men continue to be at a higher risk for infection.
Beyrer notes that in some former European colonies where 19th century sodomy laws and other anti-homosexuality statutes still exist, “LGBT people have been attacked, killed with impunity or with active state participation, and continue to face discrimination in every facet of life.” It’s no surprise that there’s only data from one African country – Kenya – in a table included in the article that shows global HIV incidence among men who have sex with men, and even that included a very small sample size of 73 people.