PxROAR member Nicholas Feustel spoke about PrEP to the German magazine Männer. What follows is a translation into English Nicholas did for us. The original article, in German, is available here.

PrEP (pre-exposure prophylaxis) is all the rage in the HIV prevention field, especially since the WHO reviewed the strategy positively. It‘s a heated debate: Do we still need to wear condoms to prevent HIV infection? Are HIV-negative people going to ‘prep‘, i.e. taking the HIV drug Truvada, the only one of which we know for sure that it can prevent HIV transmission? To help answer some of these questions, we spoke with Hamburg resident Nicholas Feustel, who advocates for PrEP.

Nicholas, you work with “AVAC – Global Advocacy for HIV Prevention”. What do they do and why are you with them?

AVAC is an organization headquartered in the USA, which advocates for biomedical HIV prevention. Much of their work is introducing new prevention options in addition to condoms. I personally would like to advocate for the destigmatization of PrEP and people who would like to take PrEP here in Germany, even before PrEP becomes available here.

Is AVAC associated with the pharmaceutical industry?

No, not at all.

Who should be taking PrEP in your opinion? Many read the World Health Organization recommendations and thought, “just because I’m gay, it doesn‘t mean that I have to take medication”.

Yes, the WHO statement was misinterpreted by very many people. The WHO is not saying that all gay men are to take PrEP, but that all gays should consider it. The WHO recommendations act also as political statements rather than individual instructions. In this case, the WHO wants to push PrEP as an option, now that we know that it works.

However, who should be taking PrEP?

The main target group are people who do not or do not always use condoms during sex. It is for those who find that condoms are not an appropriate way to protect against HIV for them. With PrEP, they could still make the decision to protect themselves from HIV. There just are many who do not get along with condoms. Be it because they lose their erection when putting on the condom or they want to be close to their partner without a latex barrier. And we know that many of the new infections occur in supposedly monogamous relationships. Or, for example for women, if it is not possible for them to get their partners to use condoms, PrEP could provide suitable protective ability. Ultimately, I do not care why people don‘t use condoms, I do not want to judge their behaviour morally. Some just don‘t, period.

But haven‘t we got used to condoms more or less? Why change our strategy now?

No one is to change their strategy. If condoms work for you, absolutely continue to use them! But consider this: When HIV and AIDS emerged, condoms were the only way to have safer sex. As a result, we got drummed for 30 years that only gays who have sex with condoms are good gays. And sex without a condom is evil, evil, evil. Imagine we already had a PrEP drug when HIV and AIDS emerged. Would people have chosen to use condoms or take a pill once a day? I think people who do not or do not always use condoms are not “hedonistic bareback sluts”. Condoms are simply not the appropriate means to protect themselves from HIV. PrEP could be an alternative for them.

Condoms also protect against other sexually transmitted infections (STIs).

Yes, but not fully. Many STIs are transmitted during oral sex. If someone who doesn‘t use condoms, but takes PrEP to protect themselves from HIV, that‘s already quite something! And also, for a new PrEP prescription you have to go to see your doctor every three months, where they will test not just for HIV but other STIs as well. With PrEP, people engaging in high-risk behavior would go to see a doctor regularly and other STIs would be detected and treated early. This might even reduce the spread of other STIs.

The drug used for PrEP, Truvada, does have side effects, right?

Commonly seen side effects of Truvada are short term gastrointestinal problems which usually disappear after a few weeks, and not everyone will experience these. Long-term side effects may include impairment of renal function and bone density. Again, not everyone will experience these. The good thing is, if you take Truvada as PrEP you can stop taking it any time.If, however, someone has been infected with HIV, they will be on treatment for the rest of their lives. When arguing against PrEP because of side effects, one must always consider PrEP and HIV therapy are two different things. PrEP with Truvada consists of two active ingredients, normal antiretroviral therapies have three active ingredients, so there is the possibility of more side effects. And in HIV therapy there is also HIV in the body—this is also a health aspect.

But we still don’t know the long-term effects of PrEP and what risk there might be.

Of course we do not know what long-term effects PrEP may have. But Truvada has been used for 10 years in HIV therapy and is considered one of the best tolerated HIV drugs. And as the activist Peter Wiesner once said: Do we know the side effect of long-term, 20 years condom use? What does it do to our psyche? Instead of being able to have truly uninhibited sex – and I think there is nothing wrong with this desire – there is this constant fear of HIV, always the bad conscience, if you didn’t use a condom.

I think these considerations are, however, irrelevant, because we do know not everyone uses condoms all the time. We have not reached these people despite 30 years of prevention messaging around “fucking with condoms”. We could tell them for another 30 years, they just won‘t. Wouldn’t it be better to offer an alternative?

Why do we only hear of Truvada? Are there no other drugs available as PrEP?

Truvada is the only one we know from studies that, when taken daily, has a really high level of protection against HIV, higher than condoms. Currently there are also so-called long-lasting injectables in development. Then PrEP could perhaps mean just a once per month injection, or every three months, and you would be protected against HIV. However, it will probably take another 10 years until that is available.

For Truvada manufacturer, Gilead, PrEP must be a gold mine.

-ish! The patent for Truvada expires in 2017, then there could be generics, that is, exactly the same active ingredients, but from another manufacturer and cheaper. This means the prices will go down then. The PrEP market is not really exciting for Gilead, because it‘s not like millions of people will take PrEP. It will be only a small group of people who find that PrEP is the better method of protection for them. Do you think PrEP will play a role in Europe? I hope so! We have to admit: we are moving towards a post-condom era.

For those who want to use them, that’s perfectly fine, but there are also many men who simply can not be bothered to continue to use them after more then 20 or 30 years of condom use. Or young people who just haven‘t experienced all the dying. They say: Sure, we know the films of yesteryear, but now those taking drugs do well. And that is also what we want to achieve with the whole anti-stigma work: Nowadays you can live a normal life with HIV. Nevertheless, I find it is worth still trying to protect yourself from HIV. Science has moved on, and we know that those drugs that let people with HIV live long and healthy lives, and under successful therapy renders them virtually uninfectious, can also protect HIV-negative people from acquiring HIV.

Data presented today at the International AIDS Conference in Melbourne and published simultaneously in the Lancet provides the first clear evidence for who wants PrEP—and how they use it outside of the United States.

While PrEP demand and demonstration projects have gathered steady momentum in the United States, the pace has been far slower in other parts of the world—including countries where some of the original trials happened. In the absence of evidence that people want and will use PrEP, there’s been plenty of debate about the viability of this strategy, particular in low- and middle-income settings.

The new data from the iPrEX Open Label Extension study (iPrEX OLE) are a welcome antidote to this skepticism. The study was open to iPrEx participants who remained HIV negative at the end of the blinded, randomized trial, as well as HIV-negative participants from two smaller safety studies. Participants were offered the chance to take daily oral tenofovir-based PrEP. Participants could also decline and remain enrolled, receiving the same counseling and care. The participants were gay men and other men who have sex with men and transgender women from Latin America, the US and South Africa. For much of the study, participants attended clinic visits every two months—less frequently than the monthly visits that were standard in the efficacy trials to date, including iPrEx.

There is much to learn from these data, and AVAC will be working with partners in the coming weeks to discuss the implications and findings in greater detail. For now, here are some key findings:

• Uptake of PrEP was higher among OLE participants than it has been in the general population of gay men, MSM and transgender women. This suggests that when people are informed—as these former trial participants were—of efficacy and safety of daily oral PrEP, they are more likely to use it. There’s a lot of work to be done to build awareness and demand in many countries—especially since the argument that “there’s low demand, so why roll it out?” is being used to justify a slow pace of oral PrEP roll out in many settings where it could reduce infections.

• PrEP works if you take it. This isn’t news but the study confirms it. In OLE, as with every other efficacy trial, people who had detectable drug in their blood—indicating that they had taken one or more PrEP doses—had less risk of HIV than those who did not. As with the original adherence/efficacy data, OLE calculated the risk at a given study visit, rather than in individuals over time. For example, the study is able to draw conclusions about the probability that someone with drug level “x” in their blood at a given study visit would test HIV positive at that visit. Higher drug levels means more protection. OLE also analyzed levels of protection based on levels corresponding to more-or-less daily dosing, compared with more infrequent dosing. Not surprisingly, more frequent dosing led to more protection. But even infrequent dosing reduced risk compared to people who weren’t taking PrEP at all. Overall, PrEP use was associated with a 50 percent reduction in risk of HIV compared to people in OLE who weren’t taking PrEP—and to HIV rates in participants in previous trials.

• People at higher risk of HIV were more likely to choose to take PrEP and more likely to take PrEP consistently over time. The study authors write, “Such preferential use of PrEP during times of greater risk is expected to increase the effect and cost effectiveness of PrEP services, and shows people’s capacity to recognize and respond appropriately to risks when given attractive options.” We couldn’t say it any better.

• Blood levels of tenofovir diphosphate (the active form of tenofovir-based PrEP) weren’t as high in transgender women, so protection also wasn’t as high. There is an urgent need to gather more data on how PrEP is used in transgender women, how tenofovir-based drugs interact with exogenous hormones, and how this strategy can be adapted for use by a population with soaring rates of HIV infection.

These are some basic top-line messages. Please subscribe to our Advocates’ Network and visit prepwatch.org for more in-depth information and analysis in the weeks to come.

Originally appeared on the Huffington Post.

Last week, the World Health Organization (WHO) issued new comprehensive guidelines for addressing HIV/AIDS in so-called “key populations” — the current global health lingo for often-marginalized populations that are heavily affected by the AIDS epidemic including gay men and other men who have sex with men, people in prison, people who inject drugs, sex workers and transgender people.

While the guidance had a number of new recommendations, the one that has received — and deserves — the most attention is the recommendation that gay men and other MSM be offered the option of oral PrEP (the use of a daily medication to reduce risk of HIV infection) as part of comprehensive HIV prevention services. It’s the first time that this new strategy has received an unqualified endorsement from WHO, and it is a most welcome development!

Unfortunately, it also highlights the work that global health agencies and funders have, to date, left undone to make the world a place where such a recommendation could be put into practice. It also risks limiting PrEP’s future impact. By inadvertently reinforcing perceptions that this option is just for gay men, the recommendation could slow efforts to deliver it to others, including millions of heterosexual women at risk for HIV.

These new WHO recommendations come two years after that agency issued guidance on PrEP demonstration projects in low-resource settings, and the US Food and Drug Administration (FDA) approved the use of daily Truvada as PrEP in the US.

The 2012 WHO guidance and FDA approval opened a new chapter in the global rollout of this effective prevention strategy, and they sent a critical message: PrEP is real, it works, and it should be made available now. The 2014 WHO recommendation on PrEP for MSM reinforces that message, and that is a good thing.

But PrEP is an option for many people, not only for gay men. (It isn’t for everybody, of course, but that is a decision to be made by individuals and their health providers.) Global health leaders should be working, now, to develop and fund programs to provide access for anyone who can benefit. Oral PrEP should be integrated into comprehensive, high-impact prevention programs for all people at risk internationally, with particular attention to key populations but also for young women and married women who continue to bear the brunt of the epidemic.

WHO needs to quickly issue guidance on PrEP for all of the populations that can benefit. The data are strong enough to warrant this move, as the US Centers for Disease Control and Prevention recently showed with its guidance that recommended that doctors consider oral PrEP for anyone at high risk of HIV infection. State and local health agencies, including in New York State, are currently conducting demonstration studies to figure out how best to get PrEP to those who need it.

Public health history tells us that a broad recommendation can actually help ensure that specific populations get access. When the hepatitis B vaccine was introduced in 1986, it was recommended only for specific populations, which ended up stigmatized the intervention. It wasn’t until it was repositioned as being a health tool for the general population that it took off.

This lesson should be borne in mind, particularly in light of the homophobic climates in many African countries with high rates of new infections in MSM, women and youth. If PrEP is viewed mainly as an option for MSM, country authorities could be resistant to providing access for anyone.

The scientific evidence of PrEP is as strong in other populations, including heterosexual women and men, and people who inject drugs. Clinical trials in multiple countries have shown that people who consistently take PrEP with oral TDF alone or in combination with emtricitabine (FTC), also known as Truvada, can reduce their risk of becoming HIV-infected by 90 percent or more.

Here in the United States, PrEP is gaining momentum, as are efforts to begin to deliver PrEP to all of the populations that can benefit.. And while gay men have been the most vocal users of PrEP so far, others are beginning to benefit. The poignant accounts by PrEP users and providers at myprepexperience.blogspot.com and just this week on the cover story of New York magazine offer hope that this new strategy will save and improve many lives, just as researchers and advocates have long hoped.

If the rest of the world follows America’s lead, PrEP could become an important global health success story. It is already being rolled out faster than earlier public health advances, from vaccines to tampons, oral contraceptive pills and the female condom — many of which took decades to get into the field. To realize PrEP’s potential, several specific things need to happen now.

In addition to expanded WHO guidance, Gilead Sciences Inc., the maker of Truvada, needs to move swiftly to secure regulatory approval in countries where PrEP is most needed. This starts with the countries that hosted clinical trials, where, tragically, PrEP is now out of reach. In two of those countries, South Africa and Thailand, Gilead recently filed for approval. This is an important and welcome step but the process needs to happen much faster and in more places. That requires both more aggressive efforts by Gilead and the willingness of national regulatory authorities to quickly review and approve the company’s applications.

Global health programs, including PEPFAR and the Global Fund, need to help countries design PrEP programs that meet the needs of their populations. A key part of this process is to launch large-scale demonstration studies in a wide range of countries and populations. Those studies can help planners understand how best to target PrEP to the people who need it most, and how to address key challenges like ensuring that people adhere to their daily medications. But so far, few of these studies outside the US have been launched or even planned.

Finally, global funders need to put substantial resources into well-planned PrEP programs. In particular, PEPFAR and the Global Fund should make sure that PrEP is not squeezed out by other funding priorities. National health authorities, who are increasingly and importantly taking ownership of their HIV prevention funding, also need to ensure a place for this intervention.

PrEP is not the perfect or only solution to the global AIDS epidemic — in fact, there is not, and never will be, such a silver bullet. We need integrated and sustained combination prevention and treatment programs. And oral PrEP as an option for all people at risk must be part of that. For the millions of people who stand to benefit from oral PrEP, let’s treat it like the advance and opportunity that it is.