PrEP: How Many Lightbulbs Does it Take to Change a Prejudice?

One of the biggest puzzles that the HIV industry hasn't answered is that it is mostly intravenous drug users and men who have sex with men who are infected with HIV in Western countries, for example, the US. But it is mostly heterosexuals, the majority of whom don't engage in particularly risky behavior, who are infected in African countries. This is a potentially huge problem for PrEP (pre-exposure prophylaxis).

There's a rather smug article on Drugs.com entitled "HIV Experts Create the Roadmap for Providing PrEP to Uninfected Individuals to Reduce the Risk of HIV Infection". But the remarks in the article, while possibly relevant to those in Western countries, seem to have little relevance to people in the highest prevalence countries. That's not unusual in articles about PrEP and HIV drugs in general, but it doesn't inspire confidence in these 'experts'.

Firstly, it is not possible to target those 'most at risk' if you don't know who they are. Most new infections in African countries are not people who could be considered to be taking a lot of risks, not sexual risks, anyhow. Take, for example, Uganda. Most new infections are among those in long term relationships, a good many of them are not promiscuous and a good many have partners who are HIV negative.

Secondly, if the risks people face are not sexual, PrEP may not be the most appropriate prevention strategy. It's obtuse to prescribe PrEP to someone who is at risk of being infected at a dental clinic, in a hospital or at a tattoo parlour. And there are far more effective and cheaper options.

If the industry doesn't accept that people face non sexual risks they will fail to protect those who are genuinely at risk. Even those whose main risks are sexual will also probably be missed out. Because of the stigma attaching to HIV where heterosexual sex is said to be the main problem (as is the case in Africa, but not elsewhere), people don't wish to be tested, to talk about their status or to even face the possibility of infection in others.

PrEP is unlikely to be the most appropriate pretection from HIV infection for intravenous drug users, either. It would be far cheaper and more effective to provide them with counselling and supplies of clean injecting equipment. But as with men having sex with men and commercial sex work, criminalization ensures that those at risk are unlikely to come forward and unlikely to get the treatment they need if they do.

If and when prep is to be considered in developing and high HIV prevalence countries, both sexual and non-sexual risks will need to be assessed. This is something that is not currently done, though it should be. Otherwise, the strategy is likely to be of little benefit and may do a lot of harm. Anti-African prejudice in the HIV industry is not often discussed, but it is in danger of scuppering their current favorite 'game changer'.