PrEP - Moving from Demonstration Projects to Wider Implementation

This was an interesting presentation in that it gave the perspective of what is happening with wider access to PrEP throughout the world, which I think is highly relevant given the recent submission for PrEP to be listed on the PBS in Australia.  It started off with a taste of the WHO's PrEP implementation tool that will be officially launched at IAS 2017 and aims to provide a framework for implementation of PrEP on current evidence to a number of stakeholders, including clinicians, pharmacists, consumers and regulatory officials.

The talk then moved on to what is happening in France, home of the ipergay study which demonstrated that on demand PrEP was efficacious.  France has been successful in implementing access to PrEP within their state funded health system and as of early 2017 had almost 3,000 people on PrEP.  The main PrEP users in France are men who have sex with men (MSM), however a strong campaign is underway to ensure other target groups within France, namely migrant and transgender women are aware of PrEP and their access to it.

Moving on to South Africa and their implementation which has focussed on two main priority groups within their context – commercial sex workers (CSW) and MSM.  Between June 2016 to June 2017, over 30,000 CSW had HIV tests and almost 2,000 were initiated on PrEP.  For the same time period, over 1,000 MSM had HIV tests and over 200 were initiated on PrEP.  Both these groups demonstrated a fairly low overall uptake with CSW uptake around 7% and MSM uptake around 21%.  The uptake within the transgender community was reported to be very low.  Possible reasons for low uptake included stigma of ART medications, even if used as PrEP and inconvenience of clinic setting and to address the latter issue, the model of care has evolved into a nurse or peer led service with more convenient hours, locations and mobility.  What is great to see is in South Africa, of the people who do commence PrEP, about 75% are women and about 75% are between the ages of 19-34, which means that PrEP is getting to the groups that need it most, as in Africa the highest growing incidence is in women and young people.  Another great outcome is the sheer number of HIV tests that are being done – a step towards addressing the first 90.

Next stop on our world tour -  England, home of the PROUD study, famously interrupted due to the high 9% incidence of HIV in the delayed PrEP group.   There are currently an estimated 6,000 people on PrEP in England, the main source is via personal importation as the NHS were not willing to fund the addition of PrEP onto the national formulary, despite two court cases to compel them to do so.  Some funding for limited places has been made available recently.  Further compelling evidence for PrEP was presented in a 42% reduction of new HIV cases between 2015 and 2016, demonstrating that PrEP is benefiting both the individual and the greater MSM community. What is interesting is that the incidence of Chlamydia has been reported as stable when compared to the number of increased tests and that cases of Gonorrhoea have indeed decreased by 24% between 2015 and 2016.  No data for syphilis was presented at this talk.  The data for the bacterial STIs is encouraging as opponents of PrEP may use the rise in these STIs as an argument against widespread implementation.

Over to Australia and the achievement of the 90, 90, 90 targets was highlighted yet despite this, stable notifications of new infections and a significant proportion of new infections (70-80%) in MSM demonstrated that in the Australian context, meeting 90, 90, 90 is just not enough to make a population impact. Small PrEP demonstration projects in 2014 in New South Wales, Victoria and Queensland with combined numbers of around 500 participants demonstrated that high risk MSM (demonstrated by high rates of other STIs on enrolment) were willing to enrol and uptake PrEP with good adherence. The taxpayer funded health system in Australia calls for a cost effective and high impact upscaling and as such, high risk MSM remain the target population.  This upscaling was implemented in the EPIC trial in NSW which has over 6,000 paticipants in that state alone (other state trials only got a brief mention but an estimated further 6,000 places combined are available).  Data presented from EPIC demonstrates that the target group of MSM is being reached, that those under 20 years of age are under represented and that Gonorrhoea notifications are continuing an upwards trend, one that was already underway before the implementation of wider use of PrEP. It appears that new HIV infections have decreased with a reported 29% reduction in all diagnoses and a 43%reduction in early diagnoses in the first quarter of 2017, compared with the previous five year average, however more data over more time is required to ascertain if this is a significant trend as a result of PrEP.  Given these figures, there is great hope that PrEP will be PBS listed and the outcome of recent submissions to the PBAC will be known late August 2017.

Kenya presented next and identified their target populations as CSW, MSM and adolescent girls and young women (AGYW).  There have been significant milestones in Kenya’s upscaling since July 2016, including national guidelines, approval of generics and a national PrEP scale up launch in May 2017.  Further information presented revealed uptake in a number of groups beyond the initial three target groups, including partners of sex workers, men who have multiple female partners and serodiscordant couples.  A substantial media campaign was adopted to attempt to address the stigma with PrEP use in Kenya.

Last but not least was a presentation on the target group of adolescent girls and young women, an over represented group in Africa with some dramatic figures – 1000 young African women dying from HIV related illnesses every day in 2015, 90% of all new infections in 15-19 year olds in girls are in Southern Africa and only a 6% reduction in HIV in women 15-24 from 2010 to 2015.  HIV in pregnant women in South Africa was also startlingly high with an 11.5 % prevalence in women under 16 years attending for antenatal care all the way up to 51.9% in those over 25 years of age.  Given the high numbers in women and pregnancy, an assessment of PrEP in a sexual health and reproductive clinic seting has been commenced and between March 2016 and February 2017, 429 women were offered PrEP with a 61% uptake, a 67.8% retention rate with adherence being reported as 90% based on pill counts.  This demonstration project will hopefully inform how to roll out PrEP to South African women in sexual health and reproductive clinics in the very near future as it is desperately needed.

“PrEP for adolescent girls and young women in Africa is NOT a luxury we can afford to withold “