1. PrEP Facts Clinical trials have shown daily oral Tenofovir to effectively prevent HIV acquisition PrEP must only be prescribed for HIV- patients and patients taking PrEP must have regular tests for HIV and other clinical conditions. WHO and other health authorities have recommended PrEP for key populations including men who have sex with men, female sex workers, women who have frequent STIs, women in discordant couples and transgender women PrEP is not contraceptive and does not protect against pregnancy.

2. The Known Unknowns Dosage Resistance Side effects and toxicity Efficacy against blood to blood transmission (injecting) Impact on condom use and sexual behaviour How health services will deal with the shift to clinic based services How will PrEP fit with social and behavioural programming What messaging/education should accompany PrEP Who should and should not be prescribed PrEP.

3. PrEP and Gender Gay men in the Global North have been the focus of PrEP clinical trials and the demand for PrEP. Female participation in trials has been limited to very high seroprevalance settings. Research has been primarily focussed on modelling efficacy ( speculative & limited to HIV outcomes) and predicting adherence. Gay men and MSM organisations promote PrEP as an alternative to condoms while the official guidance for women PrEP is to use condoms with PrEP as an additional level of protection. Consistent with the predominance of Northern men, PrEP is discussed in the language of personal choice and autonomous decision making that may not apply to women.

4. PrEP and Female Sex Workers A meta analysis of decades of literature (including pre-ARV) found that female sex workers are 14 times more likely to have HIV than non sex workers. Migration, criminality, poverty and stigma means that most sex worker populations are divided between those who can access services and those who can not. For many health spending on ‘waist down’ services is not feasible. HIV testing is a flashpoint for discrimination stigma and violence. Registration and mandatory testing is unacceptable. Sex business managers, clients and market forces play significant roles in deciding how health is protected not individual women. If condom use is eroded new industry standards will be created. Thus there is a significant risk of STIS and unwanted pregnancy. This is a rights issue as well as a public health issues where abortion and STI treatment are inaccessible and unaffordable. SO IS IT WORTH THE RISKS ?

5. Who should get PrEP, who shouldn’t and what else will be needed to make sure it works? PrEP ‘working’ does not mean preventing HIV. It means preventing HIV without causing other harms. The ‘worried well’ should not be prescribed PrEP. Only those ‘at risk’ should receive it. But who is at what risk? 2 STIs in last 12 months? How does the risk/benefit equation work in middle and low seroprevalance settings? The ethics of harm reduction vs human rights approach. How can services develop information that will prevent PrEP being misused and becoming a replacement for condoms. What legal and policy framework can best support PrEP ( rhetorical question!)