In early August, we presented two cases involving persons who were potential candidates for preexposure prophylaxis (PrEP) for HIV in Clinical Decisions,1 an interactive feature designed to assess how readers would manage a clinical problem for which there may be more than one appropriate approach to the care of the patients. The two cases involved a 46-year-old man from New York City who has sex with multiple male partners and an 18-year-old, single, heterosexual woman from South Africa who has recently become sexually active. Two experts in the prevention of HIV infection presented arguments, one in favor of the use of PrEP in these two patients and one opposed. We asked our readers to decide between these two approaches and to share their thoughts on this controversial topic.
A total of 1115 votes were cast, and the results regarding both patient vignettes were evenly divided: 51% of respondents favored initiation of PrEP for the homosexual man from New York, and 49% favored initiation of PrEP for the South African heterosexual woman; 70% of the voters gave the same response for both vignettes. Of the 30% of voters who chose different treatments for the two patients, half chose to recommend PrEP only to the man from New York and half chose to recommend PrEP only to the South African woman. Readers from 85 countries, including all regions of the globe, participated in the voting. A total of 331 voters (30%) were from countries outside Europe, the United States, Canada, Australia, and New Zealand. Interestingly, voters from the developing world were slightly less inclined to recommend PrEP, with 43% choosing PrEP for the patient in the first vignette and 47% choosing PrEP for the patient in the second vignette.
We also received 54 comments from readers in 25 different countries. Although the patients in our two case vignettes were quite distinct from one another with respect to age, lifestyle, and social status, nearly all the comments favored either treating both patients or treating neither. Among the readers who sent comments, only one favored treating one patient and not the other; this reader recommended PrEP for the man from New York only, because of a feeling that a younger person, like the woman in the second vignette, is more likely to change risky behavior with appropriate counseling, whereas an older person, like the man in the first vignette, may be less likely to respond to behavioral interventions. There did not seem to be any apparent geographic pattern to the comments; respondents from sub-Saharan Africa seemed just as divided on the topic as did those writing from Europe and the United States.
Readers who commented on their vote in favor of PrEP generally agreed that in an ideal world, we could educate people so that they would always use condoms and make smart decisions about sexual behavior; however, because it is very difficult to get people to alter their sexual practices, we should embrace PrEP as an additional tool with which to fight the spread of HIV. Those who recommended against PrEP had a multiplicity of concerns, including fears that PrEP may encourage increased license for risky sexual behavior, that resistant HIV strains may develop, and that prophylaxis may be ineffective given the low rates of adherence in the Preexposure Prophylaxis Trial for HIV Prevention among African Women (FEM-PrEP) trial.2 In addition, some readers commented that investing in treating those who are already infected with HIV would be a more efficient use of resources (as suggested by the results of the HIV Prevention Trials Network [HPTN] 052 trial3).
Determining which patients should receive PrEP is an ongoing area of uncertainty that was the subject of much discussion in the comments. Several readers expressed the opinion that patients should be given the relevant information and should be allowed to make an individual decision about PrEP with their physicians. Others wrote that we need to quickly establish guidelines to help clinicians determine which patients are at the highest risk for HIV infection and would derive the most benefit from this pharmacologic therapy.
These voting results and comments reflect disagreements within the medical and public health communities over which approaches will most effectively control the global spread of HIV. Such differences of opinion are likely to persist until the development of an effective vaccine for this devastating illness.
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