Stigma is the real issue. The first thing is that some people worry that if they are on PrEP and if somebody sees this, then they will be presumed to be positive, which is not the case. Some people have reported that and it’s an easy one to solve; you put your pills in a vitamin bottle so nobody can identify what they are. People are afraid of side effects and it’s their worry but PrEP is not a toxic drug. It just isn’t and this is where we need to educate people around this. A good example is the Needle Exchange initiative for people who use drugs. When we brought that Needle Exchange programme here a few years ago, the community revolted against us. They said, ‘Do not bring your anti-social communication here and do not associate us with drug injection behaviours. Get lost. You’re promoting drug use.’ And the same thing is happening with PrEP. They think we are promoting promiscuity.
In truth, PrEP is not for everyone. In other words it’s not sex-based therapy or a quick fix for when you think you’re going to get lucky. It is to be used as part of responsible sex menu of precaution, while you are within a monogamous relationship. That’s the ideal candidate.
It is important to have an STI screening as part of the HIV precaution package when taking PrEP, ‘Because if I’m going to drop the condoms, I accept that I may still get STIs and I need to be able to deal with that.’ PrEP will protect you adequately against HIV. condoms will give you added precaution against STIs. That’s the message. Not, ‘You must wear a condom with PrEP.’
Condoms are recommended with PrEP but we’ve got to be realistic about this. condom use is low and we’ve been trying to push condoms since 1983 and it’s actually dropping in terms of usage.
If you think about what it means to put a condom on, it is a sacrifice. Two people are getting ready to have some fun and the music is on and the lights are low; putting a condom on ruins the moment and disrupts physical sex. Our counseling includes condom promotional messages but we are realistic. If you tell us you don’t use condoms we are not going to say, ‘You bad person,’ instead what we’ll say is, ‘It’s great that you have a PrEP strategy in place for HIV but what are you doing about STIs?’ It’s a non-judgmental and affirming message that let’s you know that you’re getting one thing right but need to consider STIs too. Otherwise, if you get guilt-ed every time you come to the clinic you’re going to lie and not tell the nurse what the story is.
The fact is that PrEP is safe. The side effects are minimal. There was no risk consumption in any study done to date and it has been extensively studied. STI rates were going up before PrEPoccurred. If people cannot accept facts then you cannot have a logical argument with them.
It’s our role to take the facts and land this message correctly to counteract stigma. We have to make sure it gets to the people who need it most. The key factor in PrEP is adherence. We have to educate people on how important it is to take PrEP correctly and that means every day. We can’t blow this. We need to have a back up relinquish section for those very few people who PrEP will not work for. That is another fact that needs to be communicated. It may be 99.9% effective but for that 0.1% who will need support, we have to let them know that we are still there for them.