From Bangkok to Jakarta, Asia is witnessing a growing HIV epidemic among gay and other men who have sex with men (MSM). While the region has seen some of the world's greatest successes in anti-Aids programmes, the rapid rise in new HIV infections among MSM shows how we've failed to keep up. We need new strategies.
The epidemic of HIV among MSM in Asia is severe and substantial. Surveys indicate that in some mega-cities, including Bangkok, Hanoi and Jakarta, HIV prevalence ranges between nearly 15% and 30%. MSM, alone, accounts for about a third of newly-diagnosed HIV infections in China. Projections indicate that MSM could make up half or more of all new HIV infections in Asia by 2020.
For decades, HIV prevention has focused on condoms with immense success. In the nineties, Thailand's 100% condom programme significantly reduced HIV prevalence. But not everyone at risk of HIV opts for condoms. In most major Asian cities, less than half of MSM use condoms consistently, which is far too low to have an impact on stopping the Aids epidemic.
Sexual networking has gone through a revolution, particularly among gay men. A decade ago, casual sex between men often took place in venues like saunas, bars and hotels. Now, more and more people are meeting online, hooking up through geo-location dating applications like Grindr, Blued and Jack'd. High-risk sex can take place anywhere, anytime.
We can't ignore that people do engage in frequent condomless sex, can be part of a sexual network where new HIV infections are occurring frequently, or have an intimate partner who may be living with HIV. Sometimes, individuals lack the knowledge, skills and power to insist on condom use, placing them at substantial risk of HIV. While we must continue condom promotion, that's not enough. We need to expand choices with a new combination prevention strategy.
Enter Pre-Exposure prophylaxis, or PrEP, which is the use of antiretroviral medicine in the form of a daily pill, to prevent people from acquiring HIV. Multiple studies find taking PrEP consistently reduced the risk of HIV by more than 90%. PrEP has shown efficacy for gay and other MSM, heterosexual men and women whose partners were living with HIV, people who inject drugs and transgender women.
Three years ago, the US Food and Drug Administration approved PrEP and it is just starting to change HIV prevention for gay men and others at risk in that country. Other parts of the world have much less information. In Asia, Thailand is playing a leading role in increasing awareness and demand for PrEP.
Since early this year, the Thai Red Cross Aids Research Centre has been offering PrEP to a small number of gay men and other men who have sex with men as part of a combined pilot HIV prevention programme that includes counselling, medical testing, and education, as well as the provision of condoms and lubricants.
This week in Bangkok, experts and MSM community members, including PrEP users, are holding the first meeting of its kind in Asia, to work out a plan on how the medication can be rolled out across the region. The effort is being led by Asia Pacific Coalition on Male Sexual Health, together with the Thai Red Cross, with support from UNAIDS, the World Health Organisation, international epidemiologists and medical organisations.
Daily oral PrEP answers an unmet need in prevention for people at substantial risk of HIV. It is the only currently available option that HIV-negative people can use discreetly and not at the time of sex. However, it does not prevent other sexually transmitted infections and is not a contraceptive, so its provision is best integrated with other sexual and reproductive health services, including condoms.
The rollout of PrEP faces challenges as users need to have regular medical check-ups and evaluation, including HIV tests, and its effectiveness is highly dependent on adherence. Use of PrEP should be discussed and designed with potential users, service providers and community leaders. The key to PrEP's success in Asia will be raising awareness and increasing knowledge on how to use the regime correctly. Individuals need to make informed choices about what prevention strategies work best.
PrEP has the potential to transform HIV prevention for gay men and other men who have sex with men. Just as the birth control pill gave women freedom and expanded their choices, PrEP increases options for MSM. After all, the best prevention method is one you can use correctly and consistently.
The evidence is now overwhelming that PrEP is effective. It's time to make it available for everyone at substantial risk of HIV.
Midnight Poonkasetwattana is executive director of Asia Pacific Coalition on Male Sexual Health. Steve Kraus is director of UNAIDS Regional Support Team for Asia and the Pacific. Chris Beyrer is Professor of Epidemiology at the Johns Hopkins School of Public Health and president of the International AIDS Society.