MSMGF Welcomes CDC’s Interim PrEP Guidance for MSM in the United States
Lack of Social Acceptance and Low Access to Basic Services Undermine Advancements in Prevention
The United States Centers for Disease Control and Prevention (CDC) recently introduced Interim Guidance on the use of pre-exposure prophylaxis (PrEP) for the prevention of HIV infection among men who have sex with men (MSM). This guidance is currently aimed at healthcare providers in the US, where 53% of new infections every year occur among MSM.
The new CDC guidance follows the release of results from the iPrEx study, the first large-scale effort to examine the safety and efficacy of PrEP for preventing HIV among MSM. The multi-site iPrEx study enrolled nearly 2,500 MSM and found that PrEP was safe to use but only 44% effective, and that efficacy was only achieved when PrEP was used in combination with other well-established prevention technologies.
In its guidance, the CDC reports that “PrEP has the potential to contribute to effective and safe HIV prevention for MSM if: 1) it is targeted to MSM at high risk for HIV acquisition; 2) it is delivered as part of a comprehensive set of prevention services, including risk-reduction and PrEP medication adherence counseling, ready access to condoms, and diagnosis and treatment of sexually transmitted infections; and 3) it is accompanied by monitoring of HIV status, side effects, adherence, and risk behaviors at regular intervals.”
While the advent of PrEP is important in advancing the goal of preventing HIV infection among MSM, serious obstacles remain and must be resolved. First, the long-term safety of the drugs used in PrEP with HIV-negative men has yet to be established given that participants in the iPrEX study were followed for less than 3 years. Second, a daily pill taken over a long period of time can easily become an expensive intervention; it is not clear who will be responsible for paying for the pills, which can cost over $1,000 a month in the US. This is an especially daunting challenge for many low-income or uninsured MSM in the US, as well as MSM who live in countries where health services are difficult to access or paid for out of pocket. Finally, the iPrEX clinical trial was designed around a robust community engagement model that afforded study participants access to state-of-the-art prevention and screening services with little or no fear of stigma or discrimination. While we should strive for this standard of access and care, this is far from the current reality experienced by most MSM around the world.
In 2010, the MSMGF surveyed more than 5,000 MSM and MSM service providers worldwide. We learned that of all respondents, only 39% reported easy access to free condoms and barely one in four reported easy access to free lubricant. Large percentages of men reported that it was difficult or impossible to access other essential services, including HIV testing (57%), HIV education materials (66%) and HIV treatment (70%). The lack of access to basic HIV prevention, care and treatment services takes place against the backdrop of significant stigma, discrimination, and violence. The majority of survey participants indicated that in their countries, gay men were not accepted (60%). Nearly 20% of respondents noted that being gay was illegal in their country, and 15% said that MSM are the targets of verbal/physical assaults. Homophobic discrimination and violence have been repeatedly linked with both enhanced vulnerability to HIV as well as decreased access to HIV prevention and treatment services.
The MSMGF welcomes the addition of new tools and strategies like PrEP, but no single tool can be the silver bullet that will end the AIDS pandemic. We must continue to strive for comprehensive, balanced HIV prevention, care, treatment and support service packages that are well resourced, safe, peer-delivered, and culturally tailored to the specific needs and concerns of MSM at the local level. Research efforts and future roll-out of PrEP among MSM both within the United States and globally must engage MSM in a meaningful way at every step of the process. HIV-related services must be delivered with a commitment to the rights and dignity of MSM, as even the most cutting-edge HIV programs have little chance of success if stigma, discrimination, and violence against MSM are allowed to go unchecked.
For more information go to:
Past MSMGF Statements on PrEP