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PrEP researchers now focusing on the best ways to get PrEP to people who need it
Roger Pebody, 2016-07-18 14:30:00

Speaking to a pre-conference meeting on pre-exposure prophylaxis (PrEP) yesterday at the 21st International AIDS Conference (AIDS 2016), Chris Beyrer, president of the International AIDS Society, reminded delegates that when the International AIDS Conference was last held in Durban, South Africa – in the year 2000 – the event was notable for drawing attention to the enormous gap in access to HIV treatment between rich and poorer countries. That conference began the treatment access era.

“Now is really the time to start the PrEP access era,” Beyrer said.

The questions about whether PrEP works have been resolved. But a host of questions about the best way to implement PrEP remain, including who to offer PrEP to, where to provide it and how to stimulate demand.

To help health services and countries answer those questions, the World Health Organization (WHO) will soon issue implementation guidance, outlined to the meeting by Rachel Baggaley of WHO and Robert Grant of the University of California. The document is designed to be practical, addressing in separate chapters the needs and interests of political leaders, medicines regulators, community educators, public health officials, clinic administrators, clinicians, counsellors, testing providers, pharmacists, and monitoring and evaluation staff. A specific chapter addressed to individuals taking PrEP will answer their frequently asked questions.

WHO already suggests that “people at substantial risk of HIV” should be offered PrEP. Further, offering PrEP should be a priority in populations in which the rate of new HIV infections is 3% per year or greater.

But it has not always been clear how these principles should be applied in practice – should health services be attempting to seek out and offer PrEP to all members of a specified population? Robert Grant said that wasn’t the appropriate method; and instead outlined WHO’s three-stage approach:

  • Consider the local epidemiology: geographic, demographic, behavioural and cultural.
  • Locate PrEP services where the epidemic is occurring.
  • Offer PrEP to individuals who are at risk and who wish to start PrEP.

PrEP shouldn’t be seen as a stand-alone service, Grant said. It can be provided within or have synergies with services for sexually transmitted infections (STI), family planning, antenatal care, hepatitis B and HIV testing, as well as specialised services for men who have sex with men, sex workers, young people or workplace health.

PrEP can be a catalyst with a broad range of benefits, Rachel Baggaley said. These may include HIV testing and re-testing, regular STI screening, access to HIV treatment for individuals diagnosed with HIV and engagement with service more generally.

WHO is likely to suggest that a variety of drug regimens could be used as PrEP – the tenofovir and emtricitabine combination (Truvada) that has been most widely tested, a tenofovir and lamivudine combination, or tenofovir on its own. Countries may wish to use the same drugs for both PrEP and PEP (post-exposure prophylaxis).

Both daily and non-daily dosing schedules will be supported.

While some organisations have expressed caution about the use of PrEP for women who are pregnant or breastfeeding, WHO is likely to suggest that women can continue to take PrEP in these situations. While there are very few data on the safety of tenofovir and emtricitabine in HIV-negative women, the drugs are considered safe for pregnant women living with HIV.