The World Health Organization announced Friday that for the first time, it "strongly recommends" that men who have sex with men should consider antiretroviral drugs along with the use of condoms as an additional method of preventing HIV infection.
The health agency said that new prevention options such as pre-exposure prophylaxis (PrEP) — currently in the form of a daily pill containing two drugs — are needed alongside condom use to reduce HIV infection rates among men who have sex with men, a key population in which infection rates remain high. The agency clarified the recommendation Monday, however, stating that it was not recommending that all men who have sex with men must or should begin PrEP treatment as incorrectly reported by some media outlets.
"The recommendation states that PrEP should be considered as an additional choice for preventing HIV infection alongside and together with the use of condoms and other prevention options," WHO said in a statement to BuzzFeed explaining the recommendation. "Essentially, this is about choice — in the same way that WHO recommends different contraception options for women WHO wants to support offering gay men the full range of prevention options to suit their circumstances and not exclude any options that are evidenced based."
In its report detailing the guidelines, WHO estimates that HIV incidence among men who have sex with men could be reduced by up to 25 percent globally through PrEP and would result in 1 million fewer new infections among the group over a 10 year span. When taken consistently, PrEP has been shown to reduce the risk of HIV infection among those at high risk by up to 92 percent, according to the WHO, but noted it is much less effective if it is not taken consistently. The medication, marketed as Truvada in the U.S., is the only drug to be approved for PrEP by the Food and Drug Administration.
The organization issued the new recommendation as a part of comprehensive guidelines warning that countries' failure to provide necessary HIV treatment and services to "key groups" such as men who have sex with men, people in prison, injection drug users, sex workers, and transgender people threatens progress in the fight against HIV/AIDS worldwide. In other words, groups at highest risk of HIV are not getting the services they need, and "preventive efforts are still lagging too far behind," according to WHO.
WHO cites studies indicating men who have sex with men are 19 times more likely to have HIV than the general population. Additionally, the agency said women sex workers are 14 times more likely to have HIV then other women and that two groups — transgender women and injection drug users — are even more likely to have HIV than the general population.
"None of these people live in isolation," said Dr. Gottfried Hirnschall, director of the HIV Department at WHO, in a statement. "Sex workers and their clients have husbands, wives and partners. Some inject drugs. Many have children. Failure to provide services to the people who are at greatest risk of HIV jeopardizes further progress against the global epidemic and threatens the health and wellbeing of individuals, their families and the broader community."
The WHO guidelines urge countries to end political and social barriers to HIV services and treatments, noting that many countries reinforce discrimination with laws criminalizing actual or perceived sexual orientation, gender expression, and drug use. In the new guidelines, the organization said over 80 countries have laws prohibiting sex between men with various levels of enforcement.
"Discriminatory legislation, stigma (including by health workers) and homophobic violence in many countries pose major barriers to providing HIV services for men who have sex with men and limit their use of what services do exist," WHO states in the guidelines. "Many countries criminalize sex with the same gender (either male-male only or both male-male and female-female)."
In countries with fewer social and political obstacles to treatment for these key groups, HIV deaths have declined and new infection rates have decreased. The organization plans to call on governments to change its policies and strengthen HIV programs at the International AIDS Conference beginning July 20 in Melbourne, Australia. "Bold policies can deliver bold results," said Dr. Rachel Baggaley, from WHO's HIV Department, in the statement.
In the U.S., the Centers for Disease Control and Prevention (CDC), issued specific guidelines for PrEP in May, saying doctors with patients at high risk for HIV infection should consider prescribing the treatment as a form of prevention along with condom use.
The CDC's endorsement and now the recommendation from WHO, comes despite vocal critics of the drug who question its efficacy and say people taking it will stop using condoms, thus exposing themselves to other sexually transmitted diseases. In a statement in response to the CDC guidelines, one such critic, Michael Weinstein of the AIDS Healthcare Foundation, said, "What about other STDs like syphilis, which has seen a resurgence approaching epidemic proportions in some of the same communities that the CDC wants to target for PrEP? Despite CDC and FDA requirements for risk-reduction counseling and condom use while taking PrEP, the government-sanctioned widespread deployment of PrEP will be accompanied with a shift to condom-less sex."
However, other HIV/AIDS advocates and clinicians welcome the recommendation from WHO. Dr. Demetre Daskalakis, medical director of Ambulatory HIV Services at Mount Sinai Hospital in New York City, has prescribed PrEP to patients and served on the FDA panel recommending the medication to be used as PrEP treatment. Daskalakis hopes the WHO guidelines will open the door for an international response to the option of PrEP along with existing HIV prevention methods.
"It's a huge," Daskalakis told BuzzFeed. "This recommendation really means that you should consider PrEP as an additional means of prevention along with condoms. It's a big deal for the World Health Organization to acknowledge that PrEP is an important tool in the toolbox."