Basil Jarrett | A case for PrEP

October is Breast Cancer Awareness Month and at the time of this writing, I promise I’m wearing my pink polo shirt in support of the movement to spread awareness, encourage screening, and find a cure. So forgive me if I take a slight detour today to talk about another important public health issue that still deserves our attention, despite its slow withdrawal from our collective psyche in recent years.

Jamaica has both a generalised and a concentrated HIV epidemic. In 1996, adult HIV prevalence stood at 1.5 per cent of the general population. In 2007, those numbers inched up to about 1.8 per cent, and by 2018, the numbers again stood at 1.5 per cent. Today, an estimated 30,000 Jamaicans are living with HIV. Part of the reason behind the control of the numbers was the proactive approach taken by the Ministry of Health and Wellness in adopting an active, multisectoral response to the epidemic.

WHAT THE NUMBERS SAY

The above numbers are a bit misleading however, as the somewhat encouraging figures disguise a larger concentration among populations who are at a higher risk for HIV, namely men who sex with men and female sex workers. HIV prevalence among the former is still high, despite showing a slight reduction between 2011 (31.4 per cent) and 2017 (29.6 per cent).

Critical policy initiatives that have been implemented to reduce barriers to HIV prevention and treatment services, including improving access to condoms, contraceptives and antiretroviral (ARVs) treatment, seem to be working. But while HIV spread in Jamaica has slowed, the UNAIDS 95-95-95 Fast Track goals are still lagging. These goals state that by 2030, 95 per cent of people living with HIV will know their HIV status, 95 per cent of people who know their status will be receiving treatment and 95 per cent of people on HIV treatment will have a suppressed viral load so their immune system remains strong. A tall order yes, but if those goals are to be realised, our HIV programme must be comprehensively strengthened by policy that affirms the rights of the marginalised, reduce stigma and discrimination, and very importantly, introduce new technologies such as Pre-Exposure Prophylaxis (PrEP).

WHAT IS PrEP

PrEP, is a medication that when taken daily, can significantly reduce the risk of HIV infection. According to the Center for Disease Control and Prevention (CDC), when taken consistently, PrEP can reduce a person’s risk of getting HIV from sex by 99 per cent. Those numbers are even better than the best COVID-19 vaccine. It is a powerful preventive tool that should be explored by all people who feel like they have a risk of contracting HIV – gay, straight, or whatever describes you.

But PrEP, though a critical prevention measure that can significantly reduce the likelihood of contracting HIV, has received very little attention from sexually active adults – you know, the people who need it most. PrEP is readily available in Jamaica and can be accessed through public health facilities and some private providers. What’s more, PrEP is free at public health facilities, making availability and distribution a relative breeze. It can be a wonderful tool therefore to complement existing prevention methods like condoms and HIV testing. It offers an additional layer of protection to help individuals take control of their own sexual health and can help to reduce the stigma surrounding HIV, by sending a message that HIV prevention should be a concern for all persons.

PrEP MYTHS

With over 37 million people worldwide living with HIV or AIDS, PrEP seems like a wonder drug, however due to persisting stigma around HIV, combined with a lack of knowledge and awareness, especially among the heterosexual community, PrEP uptake remains low. Compounding the problem is this annoyingly persistent myth that PrEP is not for “straight” people. That one is a head scratcher. Is there a gay or straight condom? Or gay or straight ARV? Then how could something that gives up to 99 per cent protection against HIV be shunned because “I don’t want people to think I’m gay”? It is a perception problem that must be tackled, along with other operational challenges that hamper uptake such as the many hoops that need to be navigated in order to get the pills. Some of these issues are being addressed I am told, as getting started on PrEP is now much easier than before.

Then there is the issue of scheduling which is also a bit complicated. PrEP is most effective when taken every day and so, adhering to this regimen may be challenging for many. I can’t even remember to take my daily fish oils and vitamins without an app to remind me. I think I speak for most men when I say we wouldn’t have the discipline to stick to such a regimented schedule. For some men however, studies have shown that taking the pills a day before an unprotected entanglement, followed by another set afterwards, gives similar levels of protection as daily dosing.

PANDORA’S BOX

To my mind however, the biggest worry – and my strongest fear – is that PrEP, while closing the door shut on HIV, could open the floodgate for riskier sexual behaviour and other STIs/STDs. Widespread use of PrEP without it being part of a combination prevention package, could potentially lead to a rise in other sexually transmitted infections, straining our beleaguered healthcare system even further.

In conversations with public health experts, I have expressed my concerns about this latter issue. Condoms protect against both HIV and other STIs and STDs so why not just push and promote condoms more, I ask? The simple answer I’m told, is that condom use, like the abstinence message, is increasingly falling flat. Do you therefore try to push a message that is increasingly being ignored? Or do you admit and accept the reality that in all likelihood, condoms and abstinence will continue to be less appealing and people will continue to do what they are currently doing – that is, having more unprotected entanglements.

It’s a big question for the policy makers. Close the door on HIV and accept the potential uptick in the smaller, less problematic STIs/STDs? Or continue to push a message that is not being heard by anyone?

To my mind, we should indeed do more to make PrEP a major part of a comprehensive HIV prevention strategy. Clearly this would have to be accompanied by a robust public education and awareness campaign that promotes PrEP. The importance of continued condom use and regular testing should still be retained however, as I don’t see the two as being mutually exclusive.

It’s a complicated matter with no clear answer. And this is before other critical stakeholders – church, educators, etc. – have weighed in on the matter. But it’s a conversation that I believe should be elevated in light of the current trends.

Major Basil Jarrett is a Communications Strategist and CEO of Artemis Consulting. Follow him on Twitter, Instagram, Threads @IamBasilJarrett and linkedin.com/in/basiljarrett