I went to a bunch of Pre-Exposure Prophylaxis (PrEP) workshops and was confronted not by medical doctors who insist that PrEP is a magic bullet: rather they discussed how far we are to understanding the implementation of PrEP. They challenged us to rethink the HIV Prevention Toolkits available in our communities.
PrEP does have a value. For some couples, the need to have a baby outweighs HIV risk. PrEP is not lifelong, it is – as one plenary speaker described – for “a season of vulnerability.” For couples this is during conception, but other people may experience this season of vulnerability may be at the beginning of the relationship, for other it might be a few years into a relationship. For some, this season does not end – when domestic abuse or substance abuse is present, for instance. For some populations like MSM and transgender, the epidemic is so concentrated that we still need to understand if there is a season of vulnerability – or how that risk is shaped by time, place or partner.
Is PrEP appropriate for a generalized epidemic? South Africa has been heavily involved in PrEP studies. PrEP, as a clinical intervention, is contextualized within healthcare systems and thus this is integral to understanding the implementation. Who pays and how effective is the healthcare system at reaching those most in need of service? How do you make all health care providers and public health practitioners aware of the options? How do you get potential clients who could use the service to actually accept it? These are key questions in the implementation of any intervention; one that is not fully explored at the research stage.
The PrEP discussion was most surprising to me because all speakers spoke to the need to critically reconstruct and reconceptualize HIV prevention packages. To do this, public health policy makers, clinicians and community leaders must determine what gets taken out and what gets put into the prevention package. For MSM, for instance, the presenters pointed out that this package consisted of: no single government-brand condom, MSM-specific sites and resources, lubrication, lubrication, lubrication, and the full range of biomedical technologies available (anti-retroviral therapy, PrEP, Post-Exposure Prophylaxis, HIV testing, STD screening, Hepatitis B testing and vaccination).
This concept was inspiring. I wonder if we are ready to take ownership of our prevention packages locally in this country; I wonder if we know how to cross the divides between public health and social sciences to understand these seasons of vulnerability; I wonder these things since – for so many decades – we provided gay men condoms without lubrication and expected the condoms to be used. It is this lack of basic understanding about the communities we profess to serve that warns me away from too much hope. It’s time to get dirty again, and too many are concerned with: being liked, being agreeable, being stuck in some nostalgic time slot of the epidemic, feeling stupid in the face of different kinds of training and science, waiting on someone else to take the lead, or unable to talk about the simple elegance of lube.
Written by Dr. Andrew Spieldenner