NZAF Executive Director Shaun Robinson discusses perspectives around Pre-Exposure Prophylaxis (PrEP) and need for being realistic in its limitations. This piece is in response to Dr Charles Farthing's comments here Shaun Robinson/NZAF There are many reasons not to see PrEP as a way of preventing HIV at a community level, but probably the most obvious is this – PrEP is asking gay men to take pills so that they won’t have to take pills. It is saying to gay and bisexual men ‘take HIV medication and take it regularly or you will catch HIV and then have to take HIV medication and take it regularly’. That is rather ridiculous. These medications are pretty heavy-duty despite improvements over the last decade and you really have to ask why many people would want to take them if they don’t have to. The failure of people to take them in PrEP trials tends to prove this point. Adherence to medication is an issue for many who have HIV and they have very strong incentives to be regular with their meds, so we can be pretty sure that PrEP as a regular thing for men will be problematic. We need to remember that studies on drugs and treatments are often conducted in a controlled environment. Real life seldom mirrors controlled conditions and human behaviour varies vastly so what guys will do around PrEP in the real world may vary a lot form what happens in clinical trials. Even if three monthly injections evolve there are still major problems with PrEP as a way to stop HIV. If you are having sex with a guy how will you really know if he has taken PrEP properly whether by injection or pills? How many straight guys do you know how have become fathers unwittingly thinking their girlfriend was ‘on the pill’? By contrast you know if your partner has put a condom on because you can see it. Besides, PrEP by an injection or a pill won’t protect you from Syphilis and Gonorrhoea (Syphilis cases in Melbourne have more than doubled in gay men since 2010 for example!). Condoms do offer the best protection against a host of Sexually Transmitted Infections (STIs) very effectively. What we want from any preventive effect of medications is to add that to the preventive effects of our condom culture. We don’t want the community to be worse off overall which is what will happen if guys rely on medications for prevention and stop using condoms. We can also see that PrEP is not effective globally; countries that have reduced their emphasis on condom use are experiencing alarming increases in HIV amongst gay men (a 32% increase in Australia since 2010 for example). There are alarming increases in HIV amongst gay men around the world, but it’s worthwhile to point out how well New Zealand has done in contrast. New Zealand’s condom culture is one of the best in the world; 80% of gay men use condoms most of the time for casual sex. Condom use has protected the New Zealand gay community from high levels of HIV extremely well. Let’s not gamble with success. Shaun Robinson - 4th April 2014