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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,”
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
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.