April 29, 2014
Welcome again to our new Blog Series that brings you state of the science and health equity findings, as well as community reactions to scientific breakthroughs. Keep us posted of what you are reading and we will do the same!
This week we have a special focus on the HIV Prevention Pill or PrEP (Pre-exposure Prophalaxis). This is a relatively new HIV prevention tool where people who are at high risk of becoming infected can take a daily medication to lower the chance that they will get infected. This has been approved by the US Food and Drug Administration (in 2012) and the Centers for Disease Control and Prevention has published guidance on prescribing PrEP; while research has shown evidence of its effectiveness, is still a lot to understand in terms of how people use the pill, access, adherence and stigmatization (which was highlighted in our blog last week). Here are some new findings on these issues from the Conference on Retroviruses and Opportunistic Infections (CROI) held this past March, as well as a journal article recently released in the Lancet.
Starting with PrEP “uptake”, which these researchers define by looking at how many people agree to be in the PrEP study out of how many people were eligible. For instance, if 100 people were screened and were eligible for the study, and 50 agreed to be in the study, the “uptake” would be 50%. A few interesting points they have in their tables are that there was a much higher uptake among 1) those self-referred vs. clinic-referred (makes sense); 2) older folks; 3) those with higher risk (also makes sense); and 4) those who already knew about PrEP.
“Uptake” in this report is not defined in the same way as in the above study. In fact it is not defined at all. It’s a bit more general. This report discusses challenges, concerns and areas for additional study around barriers for Men who have Sex with Men (MSM) in the US to utilize PrEP as a tool for HIV prevention. The key issues discussed are around communication and messaging, dosage and risk behavior. A couple of the points that resonated most with me are:
While there is some data on this already, this remains a primary concern that we hear among service providers and needs to be examined further.
From the article: “Kenneth Mayer, professor of Medicine at Harvard University and the medical research director at Fenway Health, a community centre in Boston, MA, USA, believes that as with other innovations, uptake of PrEP will be slow until knowledge of past and ongoing trials become widely known in both the MSM community and the general population. Mayer also points out that there are many more MSM actually using PrEP, but currently this is within clinical trials. Thus prescriptions could rise substantially once the current crop of clinical studies in the USA comes to an end.”
In line with the previous article, researchers found that only 1.2% of over 9,000 MSM who completed the survey reported using PrEP in the past. The survey took place in August 2013 and participants were recruited from an online sex-seeking network site. The majority of the respondents identified as white (85.7%), with 7.5% identifying as Latino and 3.9% identifying as Black. Although these percentages are low, the sample size is high – thus it would be interesting for the authors to do specific sub-population analyses and see how PrEP use and access is different within Black and Latino MSM communities.
From the source: “Although MSM in this online survey reported significant HIV risks, their experience with PEP and PrEP was limited. In order to increase PrEP uptake among MSM, PCPs need to be educated to provide culturally competent care, so that patients will be comfortable discussing HIV risks that could be decreased by PEP or PrEP.”
Injection with equipment that has HIV is the most “efficient” way to contract the virus. Meaning, one is at the highest risk of contracting the virus by sharing injecting equipment such as needles, cotton, and water (compared to contracting HIV through sex). Although the rate of HIV among people who inject has dropped dramatically, PrEP may be another tool to help “get to zero,” the slogan representing the global goal of “Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths.” One of the main concerns for this, however, is that one gets the medication through a doctor, and that many people who inject may not have access to a doctor or insurance. This study interviewed over 300 HIV-negative injection drug users and found two interesting points:
This second point addresses a major concern some people have – that if a person has this prevention pill, then that person wouldn’t use any other protection. Based on the above article, it doesn’t appear that this should be a primary concern; however, there is plenty of forthcoming research that is looking at this very concern.
From the source: “A large proportion of active IDUs in Washington, DC reported being willing to use PrEP if it were available at no cost. IDUs who were younger and had more sex partners reported to be more willing to use PrEP, suggesting that these groups could be targeted first to explore the practicality of PrEP use in this population. Further research should be done to explore availability, uptake, and adherence of PrEP among IDUs.”