A recent recommendation by the World Health Organization (WHO) was announced in mass media with headlines like “WHO Says All Gay Men Should Consider Taking Antitretroviral Drugs,” “Healthy Gay Men Urged to Take HIV Drugs,” and “The WHO Wants All Gay Men to Take HIV Prevention Medication.” So called pre-exposure prophylaxis or PrEP involves a daily regimen of a single pill combining two medications (marketed in the U.S. as Truvada).
These headlines are misleading and confusing, and the premise is questionable and troubling.
First, WHO does not use the word “gay” in its announcements of this recommendation: http://www.who.int/mediacentre/factsheets/fs360/en/ Instead, the more technically precise terminology “men who have sex with men” or MSM (along with other people at risk) is used. To non-experts this may seem like a distinction without a difference, but it points to a global problem with the stigmatization of male homosexual behavior and identity (even among many groups in the U.S.). Many men who regularly have sex with men would not identify themselves as “gay.” Unlike self-identified “gay” men, who are often connected to sexual minority social networks, media, and education, MSM “living on the down low” may live secret sex lives that are impervious to sexual health education and resources.
Moreover, the media’s misuse of the convenient term “gay” further caricatures and stigmatizes gay men as unable to manage their sexual lives safely and responsibly. However, the first decade and a half of the AIDS epidemic (1981-1996) before the introduction antiretroviral pharmaceuticals show that this stereotype is inaccurate. Grassroots gay health movements provided alternatives in a range of risk-reduction strategies.
It is also questionable whether men engaging in stigmatized behavior will have access to or be inclined to seek a pharmaceutical regimen with only one purpose.
Then there is Truvada itself. When I visited the Truvada PrEP website, I was warned before I could enter: “The information on this site is intended for residents of the United States who are 18 years of age or older.” Whom this caution is protecting is unclear, but it suggests its problematic nature.
Taking Truvada poses a risk of a variety of serious health problems, including lactic acidosis, serious liver problems, complications with hepatitis B, complications with other medications, and serious side effects.
And then there is the cost. According to the New York State Department of Health, Truvada can cost $8,000 to $14,000 per year: http://www.health.ny.gov/publications/0265/ Inequities in insurance coverage (and the fact that insurers are often more inclined to pay to fix a problem than to prevent it) may make this option prohibitively expensive.
And can we talk about medication “compliance”? Patients notoriously fail to take medications as prescribed, either because of carelessness, economic considerations, or inconvenience. Will inconsistent use of PrEP place MSM at even greater risk?
Given that there are a variety of reasons that people engage in unsafe sexual practices — judgment compromised by alcohol or drugs, coercion, ignorance, calculation, denial, among others — the WHO proposal may seem like a responsible recommendation.
However, it seems to me to be an opportunity for renewed conversations and negotiations around concepts of responsible sexual behavior, consent, and risk reduction.
The answer isn’t in a little blue pill.