PrEP: A new tool for HIV prevention
The PrEP debate has been raging overseas in the past few years. In Australia, trials are set to begin this year. Lance Feeney casts an eye over the issues surrounding the controversial HIV prevention drug.
Taking a preventative drug before exposure to bacteria, viruses or parasites is not a new concept. It is called pre-exposure prophylaxis. For example, if you travel to an area where infection with malaria is common, you can take malaria medication before and during travel to prevent getting infected if bitten by a mosquito carrying the malaria parasite. Pre-exposure prophylaxis for HIV (PrEP) is a new HIV prevention concept in which people who do not have HIV infection take a daily dose of an HIV antiretroviral (usually TRUVADA) to reduce their risk of becoming infected. The drug prevents HIV from making new virus after it enters the body. PrEP can prevent the virus from establishing a permanent infection, i.e. the medication eliminates the infection before it takes hold.
When used consistently, PrEP has been shown in studies such as iPrEX, the Partners PrEP Study and TDF2, to reduce the risk of HIV infection among gay men and heterosexual men and women. In the US, its effectiveness in preventing HIV infection when injecting drugs is currently being evaluated. TRUVADA was approved for use as PrEP in the United States in 2012, however initial uptake was slow. But, San Francisco physicians have noticed a major increase in the number of people asking for TRUVADA.
Although applications have been made for the use of TRUVADA as PrEP in South Africa, Thailand, and France, manufacturer Gilead is yet to put an application to the Therapeutic Goods Administration (TGA) for its use as PrEP in Australia.
HIV advocates in Australia are backing PrEP as another tool in HIV prevention. “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,” said HIV advocate Bill Whittaker. “Obviously, PrEP is not going to be for everyone: it’s a choice, but for people who are at high risk of HIV, then they can take medication to avoid becoming infected, [and] it’s a win for them, it’s a win for public health, and it’s a win for the bottom line and the health dollar.”
Professor Andrew Grulich, head of the HIV Epidemiology and Prevention Program at the Kirby Institute UNSW, is leading Australian trials to examine the use of TRUVADA to prevent HIV infection. The Study called PrELUDE will recruit 300 people and provide access to TRUVADA for people at high risk of HIV. “We often talk about three pillars of the [HIV] response: people testing early, treating early, and maintaining safe sexual behaviour, but I think that PrEP is an important fourth pillar because the other pillars don’t do a lot for an HIV-negative gay man who’s in a highly sexually active phase of his life, and who has lots of casual partners,” Grulich said.
The PrELUDE study is an exciting HIV prevention initiative and the Kirby Institute and the NSW Ministry of Health are to be congratulated for progressing this critical prevention intervention. Every HIV diagnosis is one too many and PrELUDE will help us end HIV transmission.
However, it must be acknowledged that results from PrELUDE will take time to be realised. Gilead will need to make an application to the TGA for TRUVADA to be licenced for use as PrEP. In addition, it is unclear whether TRUVADA will be subsidised through the Pharmaceutical Benefits Scheme for use as PrEP – currently it is only licenced for treatment of people diagnosed with HIV. It may be years before TRUVADA is licenced in Australia for PrEP.
Gay men are however an innovative and resourceful lot. Unsurprisingly, they have been accessing information on the evolving science, efficacy, tolerability and availability of PrEP. They are increasingly talking to their doctors about PrEP, its value in their lives and how they can source it. In Sydney, GPs are assisting HIV-negative gay men to protect themselves from HIV by importing and taking generic TRUVADA. Just how HIV negative gay men and heterosexuals at high risk of acquiring HIV will utilise this new prevention strategy will be interestingly to follow.
However, not all people are in favour of the new prevention technique. There are those who warn that PrEP will simply provide gay men with another excuse to chuck away condoms and to indulge in hedonistic condomless sex and pleasure. They warn that an epidemic of STIs will follow.
Personally, I don’t think this will be the case. I think gay men will be mindful of the risk STIs like gonorrhoea or syphilis. Common sense dictates that if most gay men are taking PrEP to prevent HIV transmission and they know an STI increases transmission risk, then they’ll do everything they can to avoid both HIV and other STIs.
Data shows that the vast majority of gay men are responsible and generally do the right thing for themselves and for their partners. If this wasn’t the case, HIV infection rates in NSW would be through the roof. Empowering gay men and others at risk of HIV with knowledge about access to new prevention tools like PrEP is a sensible way forward.
Lance Feeney is the Senior Policy Advisor at Positive Life NSW is a member of the NAPWHA PozAction Group.