Sheena McCormack, de la University College de Londres, pasó ayer por el Congreso GeSIDA para exponer los beneficios de la PrEP y la experiencia que han tenido con la misma en Inglaterra, y más en concreto en Londres, donde los nuevos casos de infección ha caído un 80%.
From your experience, what is the impact of the implementation of PrEP as an HIV prevention tool?
Amazing! We started offering treatment to prevent onward transmissions when the UK guidelines changed in 2012. Although this was not universally adopted we actively promoted this in the clinic that I work in which is located in central London, and indeed people often asked for it at their first visit after diagnosis. From February 2014 we really scaled up testing with the opening of the Express which allowed people to check themselves in and take their own swabs. They saw a health care professional to have blood taken, but this streamlined approach meant that we could see a lot more people every day. The ease of testing encouraged people to come more frequencly and we diagnosed a lot of acute infection. In spite of this we saw little difference in the numbers of new infections each month. From the end of 2015 this changes and we saw an accelerated decline. The PROUD study of PrEP compared to no-PrEP reported in February 2015 and increasing numbers of gay men started to purchase their own PrEP from that point forwards. This online purchase increased substantially from October 2015 with the launch of two websites – prepster.info and iwantprepnow.co.uk. After this the decline became dramatic (80% since 2015). PrEP was the last piece in the combination prevention picture, and we definitely needed it in our setting to accelerate what would otherwise have been a slow decline in new infections.
In your opinion, what are the main aspects, both positive and negative, of offering PrEP?
Positive aspects are that it works incredibly well to prevent HIV infection. If taken as instructed it provides near perfect protection and this reduces the fear that so many feel when having sex which in turn improves the quality of sex. This helps with intimacy, self esteem and successful relationships all of which facilitate safer decisions. Public health advantages are that it encourages people to engage with prevention and test routinely which helps with the other sexually transmitted infections that do not always cause symptoms – you might only know you have syphilis or chlamydia by testing. Finally if PrEP is limited to those at risk of catching HIV then cost savings are made to the publicpurse freeing up money for other diseases.
All drugs have negative consquences and the drug most commonly used as PrEP gets into all the tissues. Most people tolerate it very well and notice no side-effects but 10% or so may take longer to adjust and a small proportion may have to discontinue.
There is broad concern about PrEP changing people’s behaviour so that they take more risk and as a consequence there are more sexually transmitted infections. This is why we designed PROUD to be able to compare PrEP users to non-PrEP users in a randomised way. We could see that a larger proporiton of PrEP users reported 10 or more partners with whom they had not used a condom in the last 3 months compared to non-PrEP users, but there was no difference in STIs which were high in both groups. The key point is that we are living through a period when sexual risk is increasing across the board for gay, straight and other populations – at least in part due to social media and a more liberal society. If we did not have PrEP then HIV would be increasing as well as the STIs – and HIV is the STI that we have to treat for a lifetime.
Has offering the HIV drug PrEP from the NHS been a cost-efficient measure?
The recent publication by Cambiano et al suggest that PrEP will be cost-saving if targeted at populations with high rates of HIV. It’s too early to tell for the whole NHS but the rapid decline in new infections in London is very promising..
We presented at the last GeSIDA Congress a document in which we showed the benefits of implementing PrEP in Spain. A year has passed and we still await a response from the Health authorities. What recommendation would you give to the politicians responsible for our health?
I would recommend implementing PrEP as soon as possible in health venues that gay men and other populations wiht high rates of HIV are already using, if necessary as a pilot. There is no substitute for collecting your own evidence and demonstration or pilot projects are a great way to do this. Various clinics including BCN Checkpoint have been supporting PrEP users for a while. This shows us that it is possible to deliver PrEP in Spain, but what the public health officials and politicians need is data – or a lot of lobbying from the people who vote for them!
Three years after the NHS decided to offer PrEP, will you make way for new HIV prevention initiatives?
I’m sorry to say that PROUD was not enough to convince the NHS, in spite of the strength of evidence. I sort of understand as the drug was very expensive when we reported PROUD and it was difficult to estimate how many people would want PrEP. That is what we are finding out now in the PrEP Impact trial which will enrol 10,000 individuals in a PrEP progamme. However, the scene has changed and there are several generic versions of PrEP in European countries. This means the cost of drug has come down dramatically, and the arguments for delaying PrEP implementation are less compelling.