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Tuesday 11 April 2017


Comment: Dr Peter Saxton on PrEP

Posted in: Health & HIV, Features
By Dr Peter Saxton - 1st June 2014

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Dr Peter Saxton
A discussion about the merits and risks of HIV pre-exposure prophylaxis (PrEP) here was inevitable, says Dr Peter Saxton, an HIV epidemiologist and gay health advocate at the University of Auckland. However he's surprised at the hyperbole from some proponents in the United States, and argues that it risks diverting attention from more radical reform.

“If giving perfectly healthy gay men chemoprophylaxis en masse and long-term is the best prevention option on the table, then I think you have to admit you’ve failed to engineer and sustain a community-based response to empower gay men,” says Dr Saxton, Director of the Gay Men’s Sexual Health research group. “It medicalises the public health response, and, problematically, relieves the Government of the need to confront the real determinants of marginalisation in our communities”.

“It’s essentially saying, “it’s simpler to prescribe drugs than build your community’s resilience.”

As a gay man I’d reply “That’s simply not good enough. You need to try harder. Our gay youth deserve better solutions.”

Saxton argues that better solutions than drug-based prevention for HIV negative gay men include confronting heterosexism; providing relevant sexuality education; reducing bullying and improving mental health; building young gay men’s confidence and assertiveness about using condoms; reducing barriers to condom access; ensuring health services are safe and appropriate for gay people; normalising sexual orientation data collection to identify and respond to health inequalities; and destigmatising sexual health - anal health in particular - so that conversations about gay men’s health don’t automatically trigger embarrassment and lead to avoidance.

“Condom negativity needs to be understood as a consequence of incomplete progress tackling these underlying cultural and systemic issues, not something that’s necessarily intrinsic to condoms themselves.”

“Yes, these solutions are all politically challenging. They take time and sustained effort. But they’re more radical and transformative than dosing healthy young gay men with drugs, and they promise better outcomes for our communities long term.”

Saxton notes other limitations of PrEP include community-level effectiveness, lack of protection against non-HIV STIs, drug resistance and cost.

“Modelling studies suggest that any community-wide benefits of PrEP can be undone if condom use among gay men declines even modestly. So, counterintuitively widespread introduction of PrEP might actually increase transmission in a community, not decrease it. That’s a particular risk for communities like New Zealand where condom use is still high and where HIV has been controlled relatively well as a result.”

“PrEP is an anti-HIV chemoprophylaxis so won’t address the rising epidemics of other STIs. In clinical trials there was low adherence to PrEP so there is concern about it accelerating drug resistance to HIV medications. And PrEP is very expensive. A real question is what other uses the tens of millions of dollars could be put to for queer communities. There’s no such thing as a free lunch in public health.”

For these reasons, says Saxton, the current debates about PrEP are also debates about consumer choice versus population health, individualism versus collectivism, and the influence of profit-seeking pharmaceutical companies versus community-based organisations.

“It also illustrates a paradox of public health: that the most effective population strategy is not necessarily the one that everybody would choose for themselves.”

“Peer-led community-based organisations like NZAF do have expertise in knowing what’s practically achievable with limited health budgets. Any intervention needs to be brought to scale, promoted and sustained, without eroding what already works, otherwise it’s just another short-lived idea.”

As to claims that condoms are anti-pleasure, Saxton argues the opposite: that in the context of sexually-driven epidemics, condoms offer gay men greater sexual freedom.

“High levels of community-wide condom use alleviate the need to make wholesale interferences in gay men’s sexual cultures. HIV prevention advice in New Zealand hasn’t argued the conservative stance that you can’t have multiple partners, that you must be monogamous, that you must always disclose your HIV status and sexual history, that you can’t have unprotected oral sex, that you can’t have adventurous sex. Its position has been that gay men can enjoy all of that autonomy, so long as just one thing is normalised – condom use for anal intercourse.”

“But you can’t do nothing in the face of these epidemics. Retaining sexual agency and control over our bodies is something that’s remained highly valued by many gay men, so condoms do seem like the better alternative.”




Dr Peter Saxton - 1st June 2014

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