PrEP Trials Underway In Australia, Despite Concern From Sex Workers

Asia and the Pacific Regional Correspondent

Trials of the pre-exposure prophylaxis (PrEP) HIV medication, Truvada, are currently underway in 3 Australian states, despite concerns from sex workers that PrEP may undermine the safer sex culture of the Australian sex industry. PrEP, is a combination of two antiretroviral drugs – those used to treat the HIV virus – which in theory prevents a non-HIV positive person from sero-converting to the virus should they come in contact with it.

In a recent online discussion exploring the potential impact of PrEP on the sex industry, Courtney, a Sydney-based sex worker, voiced her concerns about PrEP. She said, “Since the advent of HIV, Australian sex workers have worked tirelessly to create and sustain a strong culture of condom use within the sex industry. Sex workers have acted as safer sex educators to clients and to each other, which is one of the primary reasons the Australian sex industry has such low HIV rates. The fact that there have been no recorded instances of HIV transmission between sex workers and their clients in the Australian context is testament to the effectiveness of evidenced based HIV prevention strategies such as peer education, community development initiatives, peer-based sex worker organisations and the provision of free condoms... Whilst I am supportive of initiatives which reduce the transmission of HIV, I am concerned not only about the unknown side-effects and long term health impacts of a HIV negative person taking highly toxic medications, but also that there may be an increase in sexual services provided without the use of a condom, particularly if sex industry management or clients pressure workers to begin a PrEP regime in lieu of performing services with a condom. Further, PrEP doesn’t protect against unwanted pregnancies or sexually transmitted infections... PrEP may help to reduce HIV amongst certain communities in certain situations, but within the Australian sex industry, I feel that its usefulness is limited... We should also remember that in many parts of the world, what is driving the HIV epidemic is poor policy and the criminalisation of at risk populations -all the PrEP in the world is not going to change that unless sex workers, drug users, men who have sex with men, people living with HIV/AIDS and other marginalised communities are able to live with respect for their basic human rights and access to social justice.”

Janelle Fawkes, CEO, of Scarlet Alliance, the Australian Sex Workers’ Association, added her concerns to the discussion, saying, "Sex workers are concerned that funders will direct HIV prevention programming away from what has worked for sex workers. Without enhanced resourcing these outcomes won't be sustained for sex workers. On a policy level there is little recognition that important changes to laws and policing are still essential to an effective HIV response."

Julie Bates, a Sydney based sex worker activist and principle of Urban Realists, Planning and Health Consultants, agreed conceding, “Additional concerns include the possibility that some jurisdictions will mandate the use of PrEP over traditional HIV prevention measures and subsequently deny funding to evidence based sex worker programs.”

Many sex workers have also identified that an effective response to HIV within a sex industry context must include the decriminalisation of sex work. The Lancet’s HIV and Sex Work edition supported this assertion and projected that the decriminalisation of sex work would deliver a 33-46% reduction in HIV, clearly demonstrating the importance of governments to equally prioritise supportive sex industry legal frameworks.

Despite PrEP being approved by the United States Food and Drug Administration (FDA), the drug has not yet been approved for use within the Australian context by the Therapeutic Goods Administration (TGA) -the body responsible for approving the release of new drugs onto the Australian market. Rob Hetherington, general manager at Gilead Sciences -the company responsible for the development and marketing of PrEP -said the company has been in discussions with the TGA, but has not made a final decision about whether to submit an application for Truvada's approval for PrEP. According to Hetherington, "A decision to proceed will be informed by outcomes from ongoing research projects, leaders in this area and the wider HIV community."

In spite of the reticence of some sex workers in relation to issues surrounding the provision of, and access to PrEP, Australian HIV advocates are keen to see PrEP introduced in the near future. Bill Whittaker, spokesperson for the National Association of People with HIV Australia (NAPWA), said "We are 100 per cent supportive of providing the option of taking PrEP to people who are at high risk of acquiring HIV in Australia, and we see this as an essential and important new tool in our mission to end the epidemic. Obviously PrEP is not going to be for everyone; it's a choice, but for people who are at high risk of HIV, then if they can take medication to avoid becoming infected, it's a win for them, it's a win for public health, it's a win for the bottom line of the health dollar."