by Brian Kanyemba
The MSMGF AIDS 2016 Pre-Conference Action+ Access: Rights and Demands of Gay and Bisexual Men in the Global HIV Response in Durban, South Africa came at a very import time in the discussions around PrEP roll out among MSM in different communities and countries globally. Different presenters in different sessions expounded their discussion around PrEP focusing from clinical trials, demonstration and implementation projects to real every day life users. The commonality that cut across and came out very strongly where four important factors to consider as we go forward on PrEP. On top of the list is the issue of cost where funding is mainly from developmental partners and very little from domestic funding especially when it comes to the low and middle-income countries.
Daily Use of PrEP versus Intermittent Use
Stefan Baral in his presentation highlighted that PrEP works but adherence is key. He mentioned that since IPERGAY study, PROUD and iPrEX Ole pointed out that intermittent use of PrEP or taking PrEP for 4 times a week is protective, however, what is still recommended is daily use of PrEP. On this issue, Benjamin Brown on his analysis on demonstration studies conducted in South Africa pointed out that some participants where taking PrEP using sort of event driven initiative, for example some participants pointed out that they can only take PrEP only when their partners were around. However the recommendations still stand that daily use is key for effectiveness.
HIV Testing Key
Several presenters pointed out that regular testing for those who are taking PrEP is key before initiating PrEP and when taking PrEP. At least before taking PrEP when HIV positive it is a link to HIV through the test and treat Program. Recommendations from PrEP guidelines suggested that when on PrEP one should be tested for HIV at least four times a year. This is important to prevent any drug resistance in case of HIV sero-conversion in other words, PrEP is not sufficient on its own for treating HIV; if one is already infected, the virus in your body could become resistant to the two drugs in the Truvada pill.
PrEP at Home
To ease the burden on the health system, Aaron J Siegler on his presentation on a small pilot study suggested that to ease the burden where a series of tests are needed to be conducted regularly at the point of care, PrEP at home might be a solution. Aaron pointed out the feasibility of a home care system for PrEP would alleviate the patient and provider visit burdens. This concept is to supplement current care given by current PrEP providers. Such as system could alleviate 2 or 3 of the 4 annual provider visits, with monitoring conducted at home, and laboratory and behavioral results sent to the provider, allowing the clinician to remotely renew a PrEP prescription. However, this solution will work adequately in a country where the mailing system is efficient and Aaron conceded that home care for PrEP is not a universal solution.
Cost of PrEP
During the opening of the Pre-Conference the IAS President Chris Bayer highlighted the importance of making sure that PrEP should be made available to MSM and all who are at higher risk of HIV and that PrEP access should begin in earnest. However, in low and middle income countries, there is no funding for PrEP in public programs. MSM are willing to pay for PrEP if delivered at an affordable price. Chi-Tai Fang from Taiwan did a comparison on the cost structure of HIV/AIDS related lifetime medical expenditure and suggested that testing, linkage to care, ART, case management and inpatient care for those with HIV a lifetime cost per person will accumulate to US$326,191. A lifetime cost per person who has is HIV negative will have a cumulative cost of US$141,829 comparably. Scaling up Prep is cost saving. If cost is a concern then this will be a more compelling reason to start PrEP scaling up as soon as possible.
PrEP programs can be started quickly using existing facilities and staff. MSM are willing to pay for PrEP if delivered at an affordable price. Active education and outreach are needed to reach diverse groups of MSM for PrEP .Functional adherence measurements are restricted and remain limited to mostly self report and retention outcomes. Scaling of PrEP should be now and PrEP is safe and well-tolerated if monitored following international guidelines.
