The efficacy of the HIV medication Truvada as an HIV prophylaxis is very well established in the sexual health and HIV treatment/prevention world. Truvada, better known as PrEP in the HIV prevention context, is made up of the two antiviral medications emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg.

The implementation of PrEP in Asian countries is struggling to get underway in sufficient numbers and the primary reason for this is mostly due to cost. Although, there are other very significant barriers to getting at risk populations on the medication, as a way to reducing the transmission of HIV. Another barrier is that clients do not want to be seen attend clinics for fear of being ‘outed’ as either belonging to the men who have sex with men group (MSM), being transgender (TG) or being recognized as a person who injects drugs, all of which carry extreme risk in certain areas of Asia. The most clearly at risk MSM age group is those 20-24, where the greatest number of new infections are found in Asia.

There are some extremely concerning issues surrounding all of the above at risk groups. Firstly, the MSM group. Currently in Indonesia there are serious concerns arising over some parts of Indonesia whereby gay and bisexual men are being punished and prosecuted for having sex with men or engaging in group sex. Another group suffering stigma and discrimination (and are therefore having problems accessing services) are transgender individuals. The social scientist Martin Choo explained that there have been cases of clinics proving care to transgender clients (an understandably highly disadvantaged group disproportionately affected by serious health concerns) and due to either conflict and or discrimination within the clinic, information was released to the public about the identities of the transgender clients receiving care. This has obviously resulted in a serious breach to personal safety and the ability of those individuals to return to services and receive the care they need. Another example of a serious barrier to accessing PrEP in the Asian region is in the Philippines, where their current stance on drug laws is so severe that services providing NSP paraphernalia can be used against workers, resulting in incarceration. These, and other serious problems in the region are commonplace and illustrate how much work needs to be done to change attitudes and get governments and communities to see the benefits of PrEP (not to mention NSP programs, transgender health and the sex worker communities). Other barriers include a very recent redaction of funds to Vietnam by the USA and accepted public violence towards MSM/TG and other minority groups.

At this stage and from the talks at the APACC, it appears that Thailand, Taiwan and Vietnam are the countries that have so far managed trials or programs whereby these at risk populations can access PrEP and therefore work towards preventing the spread of HIV. I do not believe that any of these countries have any more than a few hundred clients accessing this prophylactic medication. It makes the situation in Australia seem like a paradise for health professionals, clients and governments, whereby there are somewhere in the vicinity of 8000 people accessing this medication. This amazingly positive number of people and positive situation overall (where attitudes allow for this to happen on an individual level and at a state government level) is believed so far to have resulted in a reduction of HIV infections by about 25%, which is a conservative number. One speaker mentioned that the gay dating app Blued has somewhere in the vicinity of 27 million users in China. This is an enormous number of at risk clients and a group that would very greatly benefit from the medication and make a huge difference in the global fight against HIV.

There is currently a global target in place (apologies I am not aware of the origin of this statistic) to get 3 million people at substantial risk on PrEP. As of October 2016, only around 100,000 people were able to access the medication. It is very clear that a lot of work needs to be done to change attitudes to PrEP, develop protocols, convince governments to assist in funding such programs and using this very effective medication to reduce the global burden of HIV.

HIV Forum—31 May 2017 (11am to 6pm)

I would like to present my interpretation of a session at the HIV Clinical Forum (for integrate inhibitors) held on the 31st May 2017. I believe this sessions was not as widely attended as the first day of the Asia Pacific AIDS and Confections Conference (APACC). Specifically, I will focus on an ‘HIV prevention 2.0’ talk by Dr Charles Boucher, who is a virology professor in Rotterdam and the scientific director (and owner) of Virology Education, Utrecht, Netherlands. Virology Education is the organisation that put together the APACC event in Hong Kong right now and have at least 8 other conferences throughout the year in a number of international locations.

Please note that the information presented here is not exhaustive and is limited by the speed at which I was able to take notes and my individual interpretation.

Dr Boucher began his talk speaking about the HIV prevention methods of circumcision, condoms, PrEP, PEP and ART. I was quite interested in the addition of circumcision to this list, because in my experience it is not often included in such lists. The evidence that male circumcision reduces HIV infections is quite strong.

The cost of prevention methods is a very significant problem across the world and very specifically in developing countries. Dr Boucher commented that governments struggle to understand the medication PrEP and do not see its effectiveness in reducing the cost of HIV ART and associated health care costs. I believe that some of the attendees and presenters have mentioned that PrEP comes at a cost of approximately $1US per day, which is completely unattainable to many persons around the world. Among these people are severely disadvantaged groups such as sex workers, transgender individuals and PWID.

Targeting strategies for each at risk population was a point made repeatedly by this speaker. It is interesting to note that the percentages of specific population transmission routes varied considerably between countries attending this conference. The sexual transmission groups in Australia are dominated by the MSM community whereas in China the most common group transmitting the virus are heterosexuals (66%).

The doctor concluded by saying that increasing annual testing and the uptake of PrEP in the high risk population of MSM is very important. Lack of substantial reductions in transmission is not due to ineffective ART provision or inadequate retention, rather, it is due to frequent early transmission. Dr Boucher seemed dubious as to achieving the goal of zero new HIV infections in 2030 and recommended closer collaboration between public health professionals and HIV health care providers. He also repeated his recommendation of targeted strategies and intervention approaches with specific reference to sexual/virological networks.

NB. I would like to say that the doctor also spoke about flyogenetics, analysis of sequences, resistance genotyping and viraemia but I am unable to accurately represent this information. I am very much looking forward to all of these presentations being accessible online and organisers of this even have informed me that 80% or more of the presentations should be available within 2-3 weeks.