By Matthew Hodson | @Matthew_Hodson

Right now it looks like there’s going to be a long wait before PrEP is made available on the NHS.

HIV organisations and activists, including us here at GMFA, are appalled. For a tantalising moment I thought the end of HIV could be in sight but, for now, that has been snatched away. There’s a palpable sense of anger.

However, within the gay community, you don’t have to look hard to see another narrative. In the comments under any of the think-pieces about the short-sightedness of the NHS decision there will be someone asking, “why can’t they just use condoms?”

It’s a valid question. Condoms are cheap and easy to use. They can prevent transmission of a wide range of viral and bacterial infections, including HIV. PrEP offers no protection against other STIs, is expensive and (like most medications) fairly toxic. So why not condoms?

Even when there was no effective treatment for HIV, and hundreds were dying, there was never a time when all gay men used condoms for anal sex all of the time. Condom use among gay men went from an extremely low-base (pre-HIV) to high levels but, even at its peak, it was far from universal and new HIV infections continued.

In recent years condom use has gradually been falling again. This is hardly surprising. Two decades ago the physical toll of HIV was all too visible. Since the arrival of successful combination therapy the numbers who get ill or die has dropped enormously. Someone diagnosed with HIV can have a normal life-expectancy. Of course the motivation to use condoms has diminished as a result.

It’s now thirty years since the government paid for TV adverts featuring icebergs and tombstones and an information campaign which included a leaflet posted to every household in the UK. Each year thousands of gay and bisexual men acquire HIV. Relatively few people with access to treatment are dying as a result, but there’s a huge bill for treatment and care. Gay men living with HIV routinely encounter ignorance and stigma. Many gay men without HIV experience anxiety around sex due to the fear of HIV. If we could end HIV now, why wouldn’t we?

The truth is, we could. We’ve seen early indicators of significant success in similar cities such as San Francisco, which have allocated substantial resources towards a ‘getting to zero’ (new HIV infections) approach. This work combines early initiation of treatment (to make those with diagnosed HIV less infectious), community-based prevention messages highlighting the ongoing role of condoms in improving sexual health, and PrEP.

Just as combination therapy works by hitting the virus from a number of different directions, so prevention works best when a combination approach is taken.

The passions inflamed by the NHS’s u-turn on PrEP can make it feel like PrEP is the only way to prevent new infections. The truth is, PrEP on its own won’t end HIV - and neither will condom use. Many won’t want to take PrEP because they won’t want to take preventative drugs or they don’t realise that they’re at risk. Many won’t use condoms because they interfere with spontaneity or physical sensation.

If we can combine the reduction in infections that we would get from making PrEP available to the number of prevented infections through condom use and add to that the preventative impact of HIV treatment (and even those other strategies that we don’t talk about often, such as monogamy or sexual delay) then we would get to the point where there would be very few new infections.

The sticking point, usually, is money. The current spend on HIV prevention is less than 2% of what we spend on treatment and care. To achieve the end to new HIV infections would require an investment that our currently fractured, austerity-hit systems are poorly placed to meet. We should be wary about any divisions within our community being used to prevent this investment.

If we are going to end HIV it won’t be because we pitted PrEP against condom use, but as a result of PrEP used in addition to condom use, and the other preventative strategies that we have adopted.

This shouldn’t be two tribes going to war about what method of prevention should be used. Now is the time for our community to come together to say that we’ve lived with the threat of HIV for long enough. Now is the time to utilise all of the weapons in the prevention armoury to prevent new infections. Now is the time to bring an end to HIV.


Matthew Hodson is the Executive Director of NAM


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