Prepping Gay Men for PrEP

December 17, 2014

Adebisi Alimi is an LGBT advocate, former AVAC PxROAR Europe member and a 2014 Aspen New Voices Fellow. This article first appeared in Project Syndicate.

In October, two groups researching the effectiveness of a potential breakthrough drug in the fight against HIV did something unusual. They announced that the therapy they were testing, an antiretroviral drug called Truvada, had proved effective enough to end the randomized phases of the trials, and that they were offering the pill to all of the studies’ participants.

The researchers found that gay men who take Truvada, in addition to using condoms when they have sex, were significantly less likely to contract HIV. This is further evidence of the effectiveness of pre-exposure prophylaxis (PrEP), a technique by which people who are HIV-negative use antiretroviral drugs to protect themselves from infection. In 2011, a trial funded by the Gates Foundation found that straight couples using Truvada reduced the risk of transmitting HIV by 73 percent.

Those fighting to prevent the spread of HIV/AIDS thus have a new tool in their arsenal. The question now is how best to deliver it to those who need it most: gay men in developing countries.

This summer, the World Health Organization took an important step to that end, recommending PrEP for all gay men and men who have sex with men, making it the first major international health organization to do so. The WHO estimates that increased use of PrEP could reduce HIV infections by up to 25 percent over the next decade among men who have sex with men (this category includes anyone with elevated risk, not just those who identify as gay).

But an important obstacle remains: the legal predicament of gay men in much of the developing world. In countries like Nigeria, where anti-homosexuality legislation has recently been approved, those following the WHO’s new PrEP guidelines could find themselves subject to imprisonment.

The climate of officially sanctioned homophobia in Nigeria has already set back the fight against AIDS. In 2006, a study found that 13 percent of men who have sex with men in Nigeria were HIV-positive, compared to 4.5 percent of all Nigerians. By 2012, the HIV rate among men who have sex with men had jumped to 17 percent. Meanwhile, an increasing number of men reported encountering homophobia at healthcare centers, making them less likely to seek help.

The consequences could not be more serious. Two years ago, a young HIV-positive Nigerian man contacted me on Facebook to tell me about his monthly ordeal at the clinic. The nurse at the hospital spent more time lecturing him on the evils of homosexuality than telling him about the drugs he was taking and their possible side effects. The man, a third-year medical student, told me that he had decided to stop going to the clinic. When I asked how he would continue treatment, he said that he had a friend abroad who could get him the drugs. Less than two years later, I saw a Facebook update announcing his death.

My Facebook friend is not the only one who has paid the price for Nigeria’s homophobia. A preliminary report from the Solidarity Alliance Nigeria, a coalition of gay, lesbian, bisexual, and transgender (LGBT) organizations, details a huge decrease in the use of HIV services by men who have sex with men in the six months following the enactment of the anti-gay legislation. The decrease ranges from 40 percent in Lagos – Nigeria’s most cosmopolitan city – to 70 percent in Kano, a predominantly Muslim state.

Nigerians living with HIV must do more than just fight the infection; they also must brave social stigma, weather discrimination by secular and religious institutions, and now, potentially, face threats from the legal system. In this environment, the promise of PrEP begins to dim, as the risks of seeking treatment outweigh the potentially life-saving benefits.

The story is similar in Uganda. Last spring, as legal persecution of gays there mounted, the government raided an HIV clinic and withheld its operating license for providing care and support to HIV-positive men who have sex with men.

As an African activist with more than ten years of experience in the fight against HIV, I hope that the WHO will build on its important first step of advising the use of PrEP. That means initiating a public conversation with countries like Nigeria, Uganda, Gambia, and Russia on the importance of inclusion in the battle against HIV.

The WHO should make it clear that while it may not be advocating for LGBT political rights, it is determined to ensure that all those who can benefit from PrEP are able to access the necessary drugs, without fear of legal consequences. Researchers, drug companies, and human-rights campaigners must take up the fight to ensure that PrEP is made available – without risk – to those who need it most.