For a community plagued by health disparities and other structural challenges, resistance to PrEP may also be an issue of power dynamics. During the Wednesday plenary at HIVR4P, we heard about a community concern that biomedical interventions like PrEP inherently shift the focus of control toward the medical establishment and government bureaucracies, and away from community. How do we overcome implementation challenges if the community does not feel it has control – or worse – if the community feels like it is being controlled?
Over the first two days of HIVR4P, what has piqued my interest is the idea presented by both Anthony Fauci and Chris Beyrer that HIV prevention strategies need to be tailored to specific populations. It’s really common sense. One size does not fit all. As Dr. Beyrer said in his Wednesday plenary presentation, there may be different standards for different populations, even in the same community. We know that treatment as prevention is an effective strategy for people living with HIV. PrEP works for men who have sex with men, serodiscordant couples, and people who inject drugs. There is hope for vaginal rings and microbicide gels that would benefit female sex workers. ARV-based prevention is a power tool in the toolbox of HIV prevention options, but it will serve us well to remember that combination prevention is not just about combining biomedical interventions.
Biomedical interventions are the shiny, new toys in the HIV prevention world. They are the electric drill and the nail gun in our prevention toolbox, but we can’t forget that the screwdrivers and hammer are still in there, too, and they have to be just as available as the power tools.
An article published as part of Lancet’s HIV and Sex Workers series in July 2014 suggested that “new biomedical technologies must be additive to, not replacements for, more established prevention modalities.” Just because we have new, effective ways to prevent HIV transmission does not mean we can afford to retreat from evidence-based prevention methods. We need to understand the local epidemic, identify key populations, and develop tailored combination prevention approaches, including behavioral and biomedical prevention options, and the community must be involved every step of the way.