So PrEP works – now what?

This afternoon’s series of lectures on the future of PrEP were incredible, and I was left reflecting on the future of PrEP in Australia. PrEP works, it really does, and I was compelled by Roel Coutinho to believe that if the correct risk groups are targeted, HIV indeed could be eradicated from Australia. There is evidence for increased transmission of STIs, but PrEP is ‘a sexual health program, not a drug’, as was eloquently conveyed by Julia Schillinger, and with PrEP there is a duty to increase testing. Linda-Gail Bekker reminded us that PrEP should be a lifestyle choice rather than a medical intervention, and there needs to be a client centred approach. And, perhaps most relevantly, Nellly Mugo talked about being community centred and integrating PrEP into other programs in the scale-up process.

Very soon, with PrEP becoming available on the Pharmaceutical Benefits Scheme, it will be imperative to engage General Practitioners in prescribing PrEP to appropriate groups. GPs will need to understand the need to combine PrEP with a preventative package that includes testing for STIs, while at the same time the use of PrEP should not be stigmatised. Like hepatitis C treatment, PrEP will need to be shifted into Primary Health Care, and Drug and Alcohol Services and Indigenous Medical Services will also need to be engaged.  All of this will need a great deal of work. But, to paraphrase Linda Bekker, if the cost is the prevention of HIV, then this price is not too high to pay.


Please see a summary of the lectures below:

Lecture 1: The intersection of PrEP and STIs

View the Abstract | View the Presentation

  • The important question is: Could an increase in sexual risk behaviours offset the benefit of PrEP??
  • Two things explain the increase in STI diagnosis increased detection and increased transmission
  • PrEP is a sexual health program, not a drug!
  • The program should include promoting condom use, HIV and other STI testing
  • STI rates were all increasing before the introduction of PrEP, while HIV diagnosis were stable
  • This may have been because of iPhone introduction (2007), and the introduction of apps such as Grinder, which may have increased high risk sexual behaviours
  • There are two possible causes of increased detection
    • The first is the Affordable Care Act which has resulted in more health coverage in 2016 compared to 2013
    • The second is an increase in lab technology and extragenital testing for STIs
  • PrEP leads to increased screening, and therefore increased treatment of STIs, which is a good thing.
  • But has there been an increase in transmission?
  • Studies have shown increases in condomless sex and increases in numbers of sex partners
  • Is there risk compensation (individual and community) because people consider themselves at decreased risk?

Take home messages:

  • Increase in STI diagnosis and risk behaviours predated PrEP
  • Although there is evidence for increased detection, there is also evidence for a true increase in transmission
  • Individual and community compensation for PrEP have lead to an increase of high risk sexual behaviours
  • STI interventions are needed – promote condom use and STI screening for those on and off PrEP, remember partner treatment


Lecture 2: The impact of PrEP on HIV incidence

View the Abstract | View the Presentation

  • Plenty of trials on PrEP efficacy – the risk reduction has been 44-100%.
  • However efficacy is dependent on adherence. If adherence is low then there is no reduction at all.
  • There is very little published data measuring the change in the incidence of HIV with the introduction of PrEP. The real change in incidence attributed to PrEP is difficult to clarify and separate out because increased surveillance and screening increases incidence.

Take home messages:

  • Target PrEP to groups at highest risk
  • High coverage and high adherence is important
  • Targeting MSM in developed countries will lower incidence and lead to elimination
  • The use of PrEP in injecting drug users should be embedded in harm reduction programs
  • Use of PrEP in migrants will have limited impact
  • In high prevalence countries PrEP can protect high incidence groups, but overall impact on HIV incidence will be limited
  • There is a need for a good medical infrastructure so patients are monitored and screened appropriately


Lecture 3: Is PrEP ready for wide deployment in 2018?

View the Abstract | View the Presentation

  • 220,000 actively using PrEP around the world
  • 153,000 in US
  • 5,000 in Africa
  • 25,000 buy PrEP globally
  • Relative risk ratio from PrEP is 0.49 (but different in different groups – adherence is important)
  • However there are 7 controversies (or myths which need to be dispelled)


Controversy 1:  Does it work for women in Africa?

The myth that PrEP does not work for women in Africa is apparently based on two RCTs in which there was low adherence and consequently low effect. Post-hoc subanalysis by sex in other studies has confirmed efficacy in women.

Controversy 2:  What is the time for PREP to work?

PrEP is less forgiving in women than men, and once daily dosing is probably better for women.

Controversy 3:  PrEP isn’t safe in pregnancy

PrEP appears safe in pregnancy in limited studies – may be offered and continued in women at substantial risk.

It is predicted that PrEP will be safe in breast feeding.

Controversy 4:  PrEP is not a good option for adolescents

2000 young women are infected in South Africa each week.

Younger people may need more support, but younger women want PrEP!

Controversy 5:  PrEP is a medical intervention

It was clarified that PrEP should be a lifestyle choice rather than a medical intervention. Make it a client-centred approach.

PrEP plus condoms = safe sex.

Controversy 6:  PrEP causes STIs

This was addressed by the previous speaker

Controversy 7:  PrEP is too expensive

PrEP should not be considered expensive if the cost is HIV!


Lecture 4: Taking the leap in PrEP scale-up A good type of challenge

View the Abstract | View the Presentation

  • UNAIDS have called for 3 million PrEP users
  • In Kenya PrEP scale up, 22,000 people have initiated PrEP

Take home messages for success of PrEP scale-up:

  • Continuous community education
  • Different delivery methods for different at-risk populations
  • Remember that it works!
  • Engage young girls
  • Work out how to motivate and measure adherence
  • Find ways to integrate into routine care (eg. antenatal, family planning clinic)
  • Measure population level impact
  • Skeptics important – help us to identify problems!


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