As POZ’s crack health writer, Ben Ryan, explains in the magazine’s most recent issue, PrEP works if you take it. Fortunately, we seem to be moving on from that debate and what’s left to figure out is whether it will ignite or extinguish the epidemic in our most vulnerable communities. One of the most pressing questions is whether PrEP will make it to black men who have sex with men (MSM), transwomen and cis-women of color in the south, or whether these groups will once again get left behind while the mainstream communities argue over the science.
I’m eager for the day when new research can help us figure out how to make sure that those who need PrEP most will have access to it and the knowledge for how to incorporate it into their lives.
Though there’s much discussion of biomedical HIV prevention these days (PrEP certainly falls into this category), the actual practice of seeking, obtaining and taking a pill is a highly behavioral act. Right now, obtaining PrEP usually means being a persistent and feisty self-advocate with good health insurance, extensive knowledge of PrEP, the willingness to jump over hurdles and the motivation to take a pill daily. It also means relying on clinical data that has thus far been almost exclusively limited to Latino MSM in South America or white MSM in the United States, as well as black heterosexual women and men in Africa. We have little comprehensive data on black MSM in the U.S., or transgender women, and no data at all on heterosexual women in North America.
Fundamentally, PrEP is pretty simple no matter who you are. If you take the pill every day, or nearly every day, you are afforded a high degree of protection against HIV infection. In practice, it’s more complicated than that. As is true with most things, social and economic disparities greatly affect a person’s access to care and medicine, and multiple factors can affect a person’s adherence.
I don’t mean to suggest that we should despair or assume that PrEP will remain beyond the reach of marginalized and vulnerable communities. It’s going to take a lot of work though to overcome the hurdles that stand in our way. Fortunately, there are some very smart advocates and scientists working toward this end, in these communities.
In HIV, healthcare, treatment and prevention it’s taken too long, too many years, for resources to be made available to those with the least access and power. PrEP offers an opportunity to greatly narrow that gap, but it’s not going to happen unless we do certain things, including:
- Talk about sex and drug use. PrEP has pulled sex and desire back out of the closet and that’s a good thing. It forces health care providers and patients to talk frankly about sex. Centers of excellence in sexual health and PrEP have begun to take shape and we all need to advocate for more of that.
- Ensure that PrEP provision is offered where people want it most. It’s hard enough to find trans friendly providers, so we must make sure that providers who do serve the trans community have the resources they need to offer PrEP. The same is true for black MSM and many heterosexual women of color, particularly in the South.
- Make sure that resources go where they are needed most. We should ensure that PrEP education for patients and providers doesn’t only go where there is already educational infrastructure in place. We are likely going to have to expand the capacity for some communities to offer PrEP services, and that should begin now.
- Conduct good qualitative research alongside other types of research. It’s not enough to know whether or not specific groups of individuals will take PrEP, we must also find out why they did or didn’t do so. Too little attention is paid to this issue, though we are beginning to learn more.