*(HIV Pre-Exposure Prophylaxis)
Across from my workplace in the US stood a beautiful building that once served as a funeral home. During my first week on the job a coworker looked out the window and said, “In the 80s and 90s, I went to about 70 funerals there.” I knew without hesitation that this coworker was talking about friends who had died of HIV/AIDS.
Since its devastating epidemic in the 1980s, HIV has loomed like a shadow over many parts of the world. For demographic groups in the US deemed to be at high-risk for HIV, “just use condoms,” has been the #1 prevention message, and it’s still prevalent in parts of the country today. This is especially true for gay and bi men, a population who for decades has been warned that sex could kill them. While it’s true that condoms prevent HIV, this do-or-die approach is riddled with fear and stigma.
Enter PrEP, a tool that despite its controversy has been redefining HIV prevention in certain parts of the world. PrEP involves taking a daily medication called Truvada (Emtricitabine/Tenofovir), which can help block HIV if it gets in the body. The medication builds a shield around a person’s CD4 T-Cells, so HIV can’t get into the cells and start multiplying. Clinical trials have demonstrated that when taken consistently and correctly, PrEP can reduce a person’s chances of getting HIV by up to 99% 1,2.
As a PrEP Navigator in the US my job was to help prospective patients find a culturally sensitive and affirming PrEP provider (doctor, nurse practitioner, physician assistant, or naturopathic doctor), and to help the patient get PrEP at low cost or for free through a combination of insurance and/or patient assistance programs. I witnessed a range of benefits and challenges to PrEP implementation in the US, but at the core I found that patients who take PrEP feel empowered and in charge of their sexual health. Contrary to what the anti-PrEP movement says, people don’t take PrEP because they hate condoms. People take PrEP because they want to prevent HIV, and in turn take all the opportunities they can to minimise transmission risks.
PrEP can be used in a multitude of situations: a woman can take PrEP to conceive with an HIV-positive partner; a person engaging in survival/transactional sex can take PrEP to prevent infection when partners don’t want to use condoms; a sero-discordant couple who has been together for 20 years can now include PrEP in their prevention toolkit. Patients on PrEP commit to HIV and STI testing every three months, medication adherence checks, and additional lab work. And while we know that some patients may stop using condoms when taking PrEP, we also know that some patients have never used condoms in the first place.
When I arrived in Sheffield in September to start my postgraduate program I was immediately curious about PrEP provision in England. Scotland was the first of the UK nations to get full NHS provision for PrEP, and through the PrEPared Trial Wales has since made PrEP available at certain Genitourinary Medicine (GUM) clinics3. England is making similar headway. In October of this year NHS England launched the PrEP Impact Trial, which will be the largest PrEP implementation trial of its kind4. Over the next three years, PrEP will be made available to 10,000 individuals at high-risk for HIV, including at Sheffield’s Royal Hallamshire Hospital. All trial clinics are expected to be up and running by April 20184.
Despite this forward movement, some are concerned that the trial is ultimately delaying PrEP provision. The Impact Trial website states: “Whilst the efficacy of PrEP has been established in multiple trials across the world, including the PROUD trial that was conducted in England, the relatively small sample prevented the results being generalised to all sexually transmitted infection (STI) clinic attendees and left unanswered key questions about large-scale use of PrEP. The PrEP Impact Trial aims to address the outstanding questions about eligibility, uptake and length of use through expanding the assessment to the scale required to obtain sufficient data”4. Having witnessed my patients struggle through the challenging healthcare system in the US to obtain PrEP, I understand how upsetting this decision may be–especially when clinical trials have demonstrated the effectiveness of PrEP. My assumption is that the NHS has deemed it necessary to evaluate PrEP use in other populations including heterosexual men and women before making a decision about a full PrEP provision, since the PROUD trial only studied PrEP use in gay and bi men and other men who have sex with men.
While I wish that NHS England had a full PrEP provision now, I see great potential for the future of PrEP in England. The latest report by Public Health England notes that new HIV diagnoses among gay and bi men have declined for the first time since the epidemic began over 30 years ago. This is largely due to the prevention efforts of five sexual health clinics in London through a combination of HIV testing, Antiretroviral Therapy (ART) for individuals who are positive, condom distribution, and the increased availability of PrEP. London has also achieved the UNAIDS 90:90:90 targets (90% of people living with HIV know their status, 90% of those who know their status are on ART; and 90% of those on ART are virally suppressed)5. Add-on targeted PrEP for individuals who need it most, and England could dramatically reduce or end new infections.
The negative comments I’ve read on NHS England press releases about PrEP are similar to those shared in the US–full of subtle and not-so-subtle homophobia: “the NHS shouldn’t cover PrEP because it’s a ‘lifestyle choice’”. If we let that argument guide public health programming, we’d have to eliminate virtually any programming that addresses a “lifestyle choice.” We’d have to get rid of tobacco cessation services, nicotine patches, blood pressure medication, treatment for substance use, weight loss programming…the list goes on.
The topic of PrEP has come up a lot here with friends when we talk about our background and interests. Most of them are enthusiastic about PrEP, though occasionally some express concern. “Has the US thought about focusing more on lifestyle education and choices?” I always cringe when I hear this because it rings of body and sex-shaming. We’ve got to stop telling people that they are making “bad choices”, especially when they are committing to an intervention like PrEP. PrEP is not for everybody, but it’s an option that works. Of the 79,000-plus individuals on PrEP in the US, there have been three documented cases of HIV6,7.
At the first annual PrEP Summit in San Francisco in December 2016, I remember one gentleman saying “With PrEP I’ve been able to have sex without crippling anxiety for the first time in my life”. Imagine what it would be like to be told that your sex life was dangerous and unsafe. Why do we say these things to people? These messages don’t take into account a human being’s basic and natural desire for intimacy and human connection. They also give the impression that we know what is best for others, when in reality each person is the expert of their own life. I think PrEP is helping to change this rhetoric.
I want PrEP for England like I want PrEP for my patients and friends back home in the US. I want to offer it to an individual so that they stay HIV-negative; I want it for the patient who will drive across England to get PrEP at a clinic where nobody recognizes him; for the undocumented patients who work in migrant camps; the HIV-negative women who take PrEP to be able to conceive with HIV-positive partners; and the patients who will cry with relief when they no longer have debilitating anxiety about HIV. These are human beings who are self-actualizing and taking care of their health, as anyone else could hope to do. While PrEP isn’t for everybody, it’s a critical tool for prevention and patient-led care. Patients know their risks, and they know what works for them. When people have information and tools available, they have choice. While much work remains regarding access and stigma reduction, I am grateful for England’s recognition of PrEP and its forward movement toward this critical prevention tool.
- Anderson PL, Glidden DV, Liu A, Buchbinder S, Lama JR, Guanira JV, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Science Translational Medicine [online]. 2012;4:151ra125. Available from: http://stm.sciencemag.org/content/4/151/151ra125 (accessed 2017 Nov 5).
- PrEPfacts.org [online]. San Francisco: San Francisco AIDS Foundation; (2015). Available from: http://women.prepfacts.org/the-research/ (accessed 2017 Nov 27).
- Terrence Higgins Trust [online]. PrEP on the NHS. UK; 2017. Available from https://www.iwantprepnow.co.uk/prep-on-the-nhs (accessed 2017 Nov 30).
- NHS England [online]. NHS England announces world’s largest single PrEP implementation trial to prevent HIV infection. Available from: https://www.england.nhs.uk/2017/08/nhs-england-announces-worlds-largest-single-prep-implementation-trial-to-prevent-hiv-infection/ (accessed 2017 Dec 3).
- Public Health England. (2017). Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK [online]. Available from:
- https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/662306/Towards_elimination_of_HIV_transmission_AIDS_and_HIV_related_deaths_in_the_UK.pdf (acessed 2017 Nov 27).
- Ryan B. PrEP fails in a third man, but this time HIV drug resistance is not to blame. POZ [online], Available from: https://www.poz.com/article/prep-fails-third-man-time-hiv-drug-resistance-blame (accessed 2017 Nov 30).
- Highleyman, L. PrEP use exceeds 79,000 in US pharmacy survey, but some groups lagging behind. NAM aidsmap [online], Available from: https://www.aidsmap.com/PrEP-use-exceeds-79000-in-US-pharmacy-survey-but-some-groups-lagging-behind/page/3072084/ (accessed 2017 Dec 1).