Last week, the World Health Organization recommended unequivocally that all HIV-negative men who have sex with men take HIV-preventing drugs like Truvada. The new guidelines build on a similar proposal from the CDC, but they go a step further, suggesting that even gay men who regularly use condoms should take these drugs as a backup measure. If doctors and men who have sex with men follow these guidelines, WHO estimates that about 1 million new infections will be prevented.
To a casual observer, WHO’s new stance on HIV-preventing drugs (or PrEP) might look like a perpetuation of noxious anti-gay stereotypes. But whatever image problem widespread PrEP use might create is dwarfed by the HIV problem that currently plagues the gay community. HIV is, quite simply, homophobic: The risk of transmission from anal sex is 18 times higher than from vaginal penetration, and condoms break more easily during anal sex than vaginal intercourse. Combine these facts with a clearly irreversible trend toward unprotected sex among gay and bi men, and you have a better picture of the impending crisis that WHO is trying to mitigate.
This bleak picture explains why WHO and the CDC recommend PrEP for traditionally “at-risk” men—i.e., men who have sex with men without consistently using condoms. But why is WHO going a step further and advocating PrEP even for those gay and bi men who do everything right? Here, I have a rather depressing insight to offer. Since I started covering PrEP and Truvada at the beginning of this year, I’ve received messages every few weeks from gay men who ask their doctor for a prescription—and are turned down. Invariably, these men use condoms but would prefer to have a backup plan. And invariably their doctors scold them and refuse to write them a prescription.
When patients ask their doctors to explain this startling dereliction of duty, they generally say the same thing: I don’t want anything to do with that. The physicians think, in other words, that once men start taking PrEP, they’ll stop using condoms—which is absolutely, demonstrably false. What WHO is trying to do, I suspect, is educate not just men who have sex with men, but also their doctors. And that, clearly, is a vital initiative. Presuming my correspondents’ experiences are at all representative, vast swaths of the medical establishment are still denying their patients access to these life-saving drugs based on some antiquated, possibly prejudiced, ideas about gay men and promiscuity.
If you’re a gay or bi man whose doctor refuses to prescribe him PrEP, please don’t email me—just direct them toward Page 44 of this WHO report, which provides a “strong recommendation” with “high quality of evidence” that all men who have sex with men should take PrEP. If they write you a prescription, thank the World Health Organization, keep using condoms, and encourage other men to follow your lead. And if, after reading the WHO report, your doctor still refuses to give you the drug, then it is time to get a new doctor.
Update, July 15: WHO has clarified that it recommends PrEP as an "additional choice for preventing HIV infection," to be used alongside "other prevention options."