The current issue of the Lancet Infectious Disease has featured an article summarizing the results of several PrEP clinical trials. Some have been largely impressive but the authors conclude by saying "The future is rich with possibility, but we have far to go to realise the full potential of PrEP". Do you think that leading funders for HIV treatment (National governments, PEPFAR, Gates foundation, Global Fund etc) should prioritize upscaling PrEP programs, given the somewhat positive results? Is it cost effective?
Cost effectiveness is related to background level of risk. Prioritising access for people at highest risk should be easy. There is no point in taking PrEP if you have one risk a year. Funding priorities should really be directed to fast-track studies of the 3-monthly injection which would overcome the difficulty of adherence with pills. Even knowing that PrEP works, lots of people either don't want daily meds or have difficulty getting support to take enough of them to maintain protection in the long term. Adherence dropped off significantly even in the open label phase of iPrEX.
We have doctors, nurses and others all over who are accidentally exposed to blood and body fluids. Access to preventive treatment is essential, especially if there is a delay in testing of the source of infection. There are specific HIPAA federal and state privacy regulations that complicate testing a source. I haven't reviewed the Lancet article, so I am not sure of the incidence of exposure or the frequncy of infection. These are just thoughts from the clinical side.
I haven't read yet the Lancet article, but I have reviewed recently the topic. I think a big, well structured trial about the efectiveness of different PrEP options in high risk contact is needed. This is the first step to move PrEP from research into practice. Well tolerated and easily accesible PrEP are also a priority before going from the lab to the clinic.
PrEP as a prevention option could be useful for persons with high risk but that too has to be treated with caution. We still have noc clue about adherence especially for any prevention option, adherence could be a challenge as immediate visible returns are not there. The context might be important for use of PrEP; for example pregnancy desire. Moreover PrEP alone cannot be the solution; it would require upscale HIV testing. Implementation requires studies regarding 'implementation' itself.
There is a recent systematic review about it also in PLoS Medicine, in which the authors stated that "PrEP was found to have the potential to be a cost-effective addition to HIV prevention programmes in specific settings":
Gomez GB, Borquez A, Case KK, Wheelock A, Vassall A, Hankins C. The cost and impact of scaling up pre-exposure prophylaxis for HIV prevention: a systematic review of cost-effectiveness modelling studies. PLoS Med. 2013;10(3):e1001401. Freely available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001401
The WHO guidelines now recommend consideration of PrEP for MSM where ever they live. It is necessary to break the cycle of infections, and PrEP can really help there.Introducing PrEo for key populations could potentially make a very significant difference.
I also have an article arguing that PrEO should be the comparator arm in future trials of HIV prevention.
PrEP is a needed intervention in high risk groups. For example, sero-discordant couples, PrEP will help to protect the negative person while the positive achives low-indetectable viral load.
PrEP no longer needs to be a trial, implementation is needed. Even in low income countries, such as Guatemala, the impact of PrEP will be very important, because prevalence in high risk groups continues to be as high as 10 years ago
There is no need to do trials. should be implemented in key population & for sero-discordant couples. Of course, the problem with adherence remains.
In addition to the cost effectiveness and adherence issues that Simon Collins raised, I am concerned about the long-term safety. Longitudinal research on adverse effects is needed, in particularly hepatic and renal toxicity, osteoporosis, and increased risk of transmission of STDs other than HIV. In my eyes it is premature to jump from research into practice without knowledge if the long-term risks and disadvantages outweigh the potential benefit of preventing HIV transmission.
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