In the US, 60% of new HIV infections are among the 2-5% of adult men who are gay, bisexual or other men who have sex with men (MSM), and rates of HIV diagnosis among MSM are increasing in many countries. It therefore seemed fitting that my warm-up to AIDS 2012 involved attending a pre-conference hosted by the MSM Global Forum. The early plenary speakers, including US Congresswoman Barbara Lee, former Australian High Court judge Michael Kirby and Dr Kevin Fenton (US CDC), highlighted the challenge of delivering effective HIV prevention and treatment when MSM in many countries are faced with hostile laws, violence and homophobia. The rights of MSM and transgender people are often precarious or non-existent and work to counter prejudice and protect these populations is vital but bruising work.
It’s anticipated that much of the debate at AIDS 2012 will relate to developments in HIV prevention science, notably the preventative benefits of antiretroviral drugs when HIV-positive people are treated effectively (treatment as prevention) or when HIV-negative people take antiretrovirals (pre-exposure prophylaxis or PrEP). Kevin Fenton in particular spoke about how treatment as prevention and PrEP, when combined with existing strategies (such as condoms, treating STIs and so on), could dramatically reduce the sexual transmission of HIV among MSM, if targeted and implemented well. However, many in the field are uncertain about how to integrate, target, deliver and evaluate these strategies.
A session on new prevention strategies featured Dr Robert Grant, lead investigator of the iPrEx trial of PrEP. Dr Grant echoed Kevin Fenton’s comments about implementation, admitting that despite the recent FDA approval of Truvada for use as PrEP, debate continues in the US about how best to target PrEP to MSM, how to facilitate access to those who will benefit most, and how to support those taking PrEP so that protection is maintained (PrEP’s efficacy is much higher among people who maintain a detectable level of the drug). Dr Grant raised some interesting issues about promoting effective PrEP use. He said that potential users should be told the realities of taking PrEP, rather than focusing on hypothetical risks. He said that potential users should be told that PrEP is highly effective if drug levels are maintained, but it is not as easy to take as you might think e.g. remembering to take pills, having to have regular HIV tests. Dr Grant argued against ‘intensive counselling’ or banning people from PrEP who report illicit drug use, saying this unnecessarily limits access and is not justified by the experience in trials.
Dr Grant argued that MSM who have unprotected anal sex are generally still motivated to protect themselves from HIV and PrEP can help them. This point was echoed by Bruno Spire (from INSERM in France), saying it had been a motivation to set up the IPERGAY trial of intermittent PrEP dosing, currently enrolling gay men in France. In response to questions about how to justify the cost of PrEP, Dr Grant made the point that PrEP is cost-effective when you think of it as a short-term use of antiretrovirals to prevent HIV infection, life-long treatment and a higher risk of comorbid conditions. It will be interesting to see if this pragmatism about PrEP will be taken up in Australia.