Postexposure Prophylaxis, Preexposure Prophylaxis or Universal Test and Treat: The Strategic Use of Antiretroviral Drugs to Prevent HIV Acquisition and Transmission. Weber, J., R. Tatoud, S. Fidler, AIDS (October 2010), Vol. 24 (suppl. 4): pp. S27-S39.
Evaluating the Cost-effectiveness of Preexposure Prophylaxis (PrEP) and Its Impact on HIV-1 Transmission in South Africa. Pretorius, C., J. Stover, L. Bollinger, et al. PLoS One (November 2010), Vol. 5 No. 11: pp. 1-10.
Because most vaccine candidates, such as PRO 2000 in December 2009, have either not made it to Phase III trials or have failed in this phase, Weber and colleagues argue that, aside from male condoms and male circumcision, antiretroviral drugs themselves have become one of the only methods for preventing new infections. This review outlines the risks and opportunities of the potential expansion of ART for prevention while questioning the scientific basis of this prevention approach. According to the authors, there are currently 26 licensed antiretroviral drugs for HIV treatment that may be adapted for HIV prevention, either singly or in combination. Several issues remain about adapting these drugs for prevention, such as cost-effectiveness, feasibility, and safety, as well as use of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) vs. a universal test and treat (UTT) approach focusing treatment and resources on the HIV-infected. The authors believe that the challenge of PrEP at the population level is greater than for UTT for several reasons, including the tremendous increase in initial and repeat HIV testing, the potential challenges of prescribing and monitoring ART in uninfected individuals, possible therapeutic confusion when using the same drugs for prevention and treatment, the possibility of drug resistance, poor adherence, and concerns about overtaxing an already weakened health care system. The authors call for increased funding for advanced clinical trials of UTT so that its effectiveness can be compared to PrEP. Using a mathematical model to examine the cost-effectiveness of PrEP in South Africa, Pretorius and colleagues found that PrEP can avert as many as 30 percent of new infections among targeted age groups of women at highest risk of infection. However, the authors note that PrEP is solely a prevention strategy, while UTT is both a treatment and prevention strategy. According to the authors, PrEP’s impact on incidence reduction is less than UTT’s, although PrEP could serve as a useful stopgap control solution until UTT coverage can be adequately achieved (which in many resource-limited settings may be a long time).
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