PrEP is coming, but who will get it?

One of the big concerns for European governments considering whether and how to make Truvada available as pre-exposure prophylaxis for HIV (PrEP) is the cost. The medication itself is expensive, and it also requires on-going support from medical providers. In many European countries these costs will be borne largely or entirely by state-funded health systems.

Studies have consistently found that to be cost-effective PrEP, needs to be used by those at the highest risk of acquiring HIV. How high? The World Health Organization suggests that giving PrEP to people in groups with an incidence of 3% per year would be cost effective, while estimates in the UK suggest a minimum incidence of 5%.

Although gay and bisexual men generally are at elevated risk of infection, not every gay or bisexual man is at equally significant risk of acquiring HIV. In the US, the Centers for Disease Control and Prevention recently estimated that about 1 in 4 sexually active HIV-negative gay and bisexual men would benefit from PrEP.

One of the most important results of the PROUD trial in the UK was that the men in the study who were not using PrEP had an extremely high incidence of 9%. The French IPERGAY trial also found that men in the control group had a high rate of incidence (6.75%). This meant not only that Truvada as PrEP was (yet again) confirmed to be extremely effective at preventing HIV, but, crucially, that both studies had been extremely successful at recruiting men at very high risk of acquiring HIV.

But these studies were relatively small, and it’s not clear that simply applying the same criteria used for participation in the studies on a wider scale will be as effective at targeting the right people, or what criteria will be appropriate in other countries. While people at the highest risk of infection have been shown to be the most motivated to seek out and use PrEP, cost-conscious health systems want to have an idea of where to draw the line for eligibility so that those at low risk of infection do not use resources that could benefit others more.

So how do health authorities make sure they can reach those at higher risk, that the people who most need PrEP get it first?

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PrEP is coming to France

Earlier this afternoon the rather exciting news broke that beginning in December Truvada will be approved for use as pre-exposure prophylaxis (PrEP) for HIV in France. France’s Minister for Social Affairs and Health, Marisol Touraine, made the announcement that her country will become the second in the world (after the US) to approve Truvada for this use, and the first to provide it free of cost.

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PrEP demonstration projects here and there

I just ran across this update from the New Zealand AIDS Foundation about a nascent PrEP Demonstration Project. Not much to tell—basically just “we’re working on it and we’ve got no money and we’re already quite busy”—but I couldn’t help raising an eyebrow at some of the language:

“We want to make PrEP available via sexual health doctors for those men who don’t wear condoms and put themselves and others at risk.”

Which echoes an earlier NZAF statement in response to the most recent WHO recommendations which noted that PrEP “has been shown to work for highly motivated individuals who resist other forms of safe sex.”

I wish them luck finding sponsors for the project, and I sincerely hope folks actually participating in this project will find the experience to be a little less, um, judgey in tone.

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