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Australia adopts ambitious plan to use PrEP to ‘virtually eliminate’ HIV by 2020
Gus Cairns, 2016-07-21 20:50:00
Australia plans an ambitious programme of pre-exposure
prophylaxis (PrEP) provision for gay men at high risk of HIV, with the aim of
‘virtually eliminating’ HIV in the gay community by 2020.
Iryna Zablotska of the University of New South Wales told
the 21st International AIDS Conference (AIDS 2016) that in order to
meet the costs of providing free PrEP to an estimated 14,000 users, generic
tenofovir and emtricitabine would be used instead of Truvada, and in order for
this to happen straight away, the PrEP rollout would initially at least be in
the form of scientific implementation studies, one per Australian state. The
New South Wales programme has already been launched under the name of EPIC-NSW.
Programmes in Victoria and Queensland are due to start soon and other states
will follow suit next year.
“There are four essential things that had to happen in
order for a PrEP programme like this to happen,” she said. “We had a Ministry
of Health that was actively committed to making PrEP happen; a positive
consensus for PrEP among medical professionals; a supportive network of sexual
health clinics and gay-friendly GPs; and a proactive LGBT health community that
devised innovative awareness and social media campaigns.”
PrEP is needed in Australia for the same reason it is in
many countries; after a peak of 2411 diagnoses in 1989, annual diagnoses fell
to 750 in 1999, but have since then slowly climbed to 1081 in 2014, and show no
signs of slackening off. Three-quarters of HIV infections in Australia are in
gay men. The Australian treatment ‘cascade’ is 88% diagnosed, 73% of them on
treatment and 92% of them virally suppressed, in other words 59% of all people
with HIV virally undetectable, 13% short of the UNAIDS 90/90/90 Target.
Australia, however, is the first country providing PrEP
to suggest that it could be what will make all the difference when
it comes to rolling back its HIV epidemic and bringing incidence down. Iryna Zablotska
agreed with session chair Helen Rees that this was the aim: “We have been very successful
with testing and treatment; PrEP might be the last tool we need,” she said.
Surveys conducted between 2011 and 2015 show accelerating
awareness of PrEP. One in 40 ‘community-attached gay men’ says they have
already taken PrEP acquired online or from friends and, depending on survey,
between one in 30 to one in ten men at the kind of risk that would be covered
by the criteria for the rollout study. A study in 2012 found that only 21% of
at-risk gay men said they would be interested in taking PrEP but by the
following year this had increased to 71%.
EPIC-NSW was launched on 1st March this year, two
months in advance of PrEP being approved for prevention use by the country's drug licensing agency. Studies supporting the adoption of PrEP included two
PrEP pilots, PrELUDE and VICPrEP, which started in New South Wales and Victoria
respectively in 2014 and still ongoing. To this has been added Qprep in
Queensland which started this year. Between them, however, they have only
enrolled 465 men. It is estimated that
100,000 gay men in Australia are at risk of HIV (one in 230 Australians) and
nearly 15,000 at the kind of risk that would meet the criteria for PrEP
These criteria are based on incidence studies, which find
that annual HIV incidence among men presenting with rectal gonorrhoea was 7%,
and with chlamydia, 3.2%. Among people with a regular HIV-positive partner who was
not virally suppressed incidence was 5.4%, among men who’d recently had condomless sex
with a partner of positive or unknown status it was 2.3%, and among methamphetamine
users it was 1.9%. The criteria for EPIC-NSW is that the person must have had one of
these risk factors in the last three months. Background incidence in PrELUDE
participants was estimated as 4%.
Based on these criteria it was estimated that 3700 MSM in
New South Wales would be eligible for PrEP but, said Iryna Zablotska, “It
appears we grossly underestimated the effect of the launch and the number of
participants.” In fact, one thousand gay men came forward for PrEP in the first two
months of the study.