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.