On Sunday, April 1, only a handful of other countries in the world whose governments have made HIV pre-exposure prophylaxis (PrEP) readily available to populations at risk of HIV infection.
This step forward takes Australia much closer to achieving its pledge, made in 2014, to .
What is prep and how does it work?
PrEP is the most powerful prevention tool currently available for people at risk of HIV infection. In people with high adherence to PrEP medication, it reduces the risk of acquiring HIV .
This compares to an HIV for men who have sex with men (MSM) and who choose consistent condom use alone to prevent HIV infection. In 2015 the World Health Organisation that PrEP should be offered as an additional HIV prevention option to all populations at substantial risk of acquiring HIV.
In its current form, PrEP involves combining two antiretroviral drugs, tenofovir and emtricitabine, into a single tablet. PrEP is usually taken daily, but may be used just as effectively by MSM in an fashion, taking tablets before and after sex.
What about side effects?
PrEP is generally well tolerated; in one study approximately 17% of people experienced . These included headache, fatigue and gastro-intestinal upset within the first few weeks of starting PrEP.
These side effects over a few months. Only 5% of people ceased PrEP because of adverse effects. PrEP does cause a small decline in the health of the kidneys and bones, but these changes are when PrEP is ceased.
People receiving PrEP see their clinician every three months to test for HIV and other sexually transmitted infections (STIs) and to monitor their overall health.
Early PrEP study results in Australia
In Australia’s first PrEP , VicPrEP, we observed a decline in condom use and a rise in sexually transmitted infections (STIs), which has been reported in other .
There are several reasons why STIs may rise in populations using PrEP. These include less condom use, but also simply that STIs are diagnosed more frequently because people on PrEP get tested for these every three months. More research and collaboration with the community are needed to better understand the relationship between PrEP and the incidence of STIs.
Despite PrEP only arriving on the PBS from April this year, Australia is already leading the world in its PrEP use. In Australia, 31,000 MSM are .
Thanks to strong partnerships between community activists, peak Australian HIV organisations, doctors, researchers and state and territory health departments, approximately 16,000 MSM receive PrEP through . Several thousand more people are thought to be personally thanks to dedicated community activists.
Early signs of success in PrEP’s ability to reduce HIV infections at a population level have come from New South Wales where, remarkably, about 9,000 people have enrolled in the .
Recently, NSW reported a 32% decline in new HIV infections and a 25% overall statewide decline in new HIV diagnoses following the rollout of .
This remarkable progress should energise and provide impetus to other jurisdictions and countries, including Asia and the Pacific and particularly Eastern Europe and Central Asia where there is a dearth of PrEP use and the incidence of over recent years.
Getting PrEP through the PBS
From April 1 2018, people with a Medicare card who are at will be able to receive a script from their general practitioner or medical specialist for a three-month supply of PrEP.
The Pharmaceutical Benefits Advisory Committee approved PrEP in , which means the will subsidise its cost. People taking PrEP will pay up to $39.50, or $6.40 per month for concession cardholders.
The Commonwealth has to peak national HIV organisations to educate healthcare providers and the community about PrEP. This education must address and prevent the risk of people seeking PrEP - that is, people seeking a key preventive health measure - from being shamed and stigmatised in any healthcare setting. Hence a transgender man should be able to request and receive a vaginal swab to test for STIs in a pathology clinic in any Australian jurisdiction with impunity.
Broader PrEP awareness needed
To date, most people enrolled in Australia’s PrEP studies have been MSM. The immediate challenge is to make sure all populations at risk of HIV in Australia are appropriately engaged with, educated about and have access to PrEP.
, including PrEP, must occur urgently with Indigenous Australians. The rate of HIV transmissions increased by 33% in 2016; the rate among non-indigenous Australians declined by 22% in the same period.
People who inject drugs, transgender people, heterosexuals and people who are ineligible for Medicare are other key populations who will benefit from PrEP.
The world does not yet have a vaccine for HIV, but Australia now has the other two pillars of biomedical prevention that are necessary to end HIV: HIV treatment, which renders an HIV-positive person’s risk of transmitting HIV to “”, and PrEP.
Let’s work towards a “Vale HIV” for 2020.
