PrEP: Is it time for the UK to follow the US?
Last week the US Centre for Disease Control (CDC) issued the first formal guidelines on pre-exposure prophylaxis (PrEP), a promising new way of preventing HIV transmission. PrEP involves people who do not have HIV taking a daily dose of one or two of the drugs that are used to treat HIV. Studies suggest that this can prevent transmission if the user is exposed to HIV.
With thousands of new infections occurring each year in the UK, PrEP presents an opportunity to cut the rate of infection and in particular may be an effective way of supporting prevention among gay men. But questions remain. We know PrEP works really well in a clinical trial if you take the medication daily as recommended. But in the real world will people do so? And will there be an effect on condom use – might it mean fewer condoms are used resulting in more STIs being spread, and thus more HIV? Will the people who want to take PrEP be the people who really need it?
Some of the key questions about how the strategy might be best employed are being addressed in the PROUD trial, a two-year study currently underway which will look at the impact of PrEP among gay and bi-sexual men. The findings will further inform use of PrEP and how we can roll it out most effectively in the UK.
These questions around the detail should not obscure our support for this exciting new prevention option. Nor should we delay too long in making PrEP available in the UK to those who are at real and imminent risk of getting HIV.
Reaction in the UK to the recent CDC guidance has been largely positive. For most commentators the public and individual health benefits to preventing further HIV infections are common sense. But some do question whether in these cash-strapped times the NHS can or should pay for PrEP. The cost of commissioning PrEP should be considered in the context of long-term savings from reducing the number of HIV infections and thus the costs of treatment. We just need to make sure PrEP is targeted effectively at those who would otherwise get HIV.
And what about the argument that PrEP is encouraging people to ‘throw away the condom’? The reality is that most people find it difficult to use condoms all of the time. NAT along with other charities working on gay men's HIV prevention have published a Statement on PrEP, which gives further information on the relation between PrEP and condom use and explains why PrEP is a welcome new prevention option to add to what we can do. This Statement makes clear that PrEP is not seen as a replacement for condom use, but that it might be an important tool in the prevention 'toolbox', providing some people with the opportunity for protection at times where they believe that they may be at higher risk of HIV infection.
Individuals who do decide to take the treatment are unlikely to do so lightly, and clinicians will be looking at ensuring consistent use of the drugs, important to efficacy of PrEP. The UK will need similar guidelines to those produced by the CDC, and support for clinicians, and those taking the medication, is essential. We will probably have to await the results of the PROUD trial to fully inform this approach; but we shouldn't hang around too long before enabling people to benefit from it.