MELBOURNE – Men who have sex with men should consider pre-exposure prophylaxis with antiretroviral medications as an additional option to prevent HIV infection, according to the latest World Health Organization guidelines on HIV prevention, diagnosis, treatment, and care in high-risk populations.
The guidelines, released at the 20th International AIDS Conference, also introduce a new recommendation on providing access to naloxone and instructions on its use for anyone likely to witness an opioid overdose in a friend or relative, as part of a broader harm-reduction effort.
Dr. Rachel Baggaley
These are the first WHO guidelines on HIV/AIDS that bring together advice on five key population groups: men who have sex with men, injection drug users, sex workers, transgender people, and people in prisons.
Dr. Rachel Baggaley, guidelines coordinator from the HIV department at WHO, said the latest UNAIDS estimates suggest up to 50% of new infections are occurring among these groups because they are not getting the services they need.
While the idea of pre-exposure prophylaxis (PrEP) among men who have sex with men was first raised 3 years ago, Dr. Baggaley said the evidence now justified a strengthening of the recommendation.
"We’re just opening the door to suggest that this can be considered as an additional prevention choice, given the high incidence rates we are continuing to see in this population," Dr. Baggaley said in an interview.
"At the moment PrEP is a daily dose, and so for gay men who would want to use it, it would be offered as a daily dose for a period of time and it would be reviewed ... in consultation with the health care provider," she said.
Other recommendations included voluntary medical male circumcision, particularly in areas with hyperendemic HIV and low prevalence of circumcision, for the prevention of heterosexually acquired HIV in men, and daily oral pre-exposure prophylaxis – tenofovir alone or tenofovir and emtricitabine – for uninfected partners of HIV-positive individuals if additional HIV prevention choices are needed.
Dr. Chris Beyrer, director of the Johns Hopkins Center for Public Health and Human Rights, Baltimore, said that the recommendation on PrEP was about providing more options for HIV prevention.
"PrEP is not being recommended as a lifetime approach – it is important for men to consider as an option for prevention when they are sexually active and at risk of HIV exposure," Dr. Beyrer told the conference.
The guidelines also recommended routine screening and management of mental health disorders such as depression and psychosocial stress among HIV-positive people from these key populations, to optimize health outcomes and improve antiretroviral adherence.
For injection drug users, the guidelines recommended all people should have access to sterile injection equipment through needle and syringe programs, as well as a recommendation for availability and training in naloxone use for opioid overdose.
Dr. Beyrer described the naloxone recommendation as a lifesaving intervention and a public health and human rights advance.
The guidelines were funded by UNAIDS, the U.S. President’s Emergency Plan for AIDS Relief, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. There were no relevant conflicts of interest declared.