Proactive Approach Protects Population From HIV

It is widely accepted that PrEP effectively reduces HIV on an individual level. The extent to which PrEP protects populations against HIV has been pretty much unknown—until now.

‘PrEP’ stands for ‘pre-exposure prophylaxis’ and refers to the regular use of HIV medicines taken by HIV-negative people before sex to reduce the risk of getting HIV. Following a massive effort to roll out PrEP across New South Wales (NSW), HIV diagnoses declined in Australia’s most populated state, from 295 in the 12 months before PrEP roll-out to 221 in the 12 months after—the lowest number since HIV surveillance began in NSW in 1985. The findings were published yesterday in The Lancet, whereby the authors concluded:

'As part of a combination prevention approach, rapid, targeted, high-coverage PrEP implementation is effective to reduce new HIV infections at the population level.’

In the study, 3700 participants (median age 36 years, IQR 30-45 years) were recruited across 21 clinics in NSW, between March and October 2016. 99% were men, 96% identified as gay, and 4% as bisexual.

Participants took a daily pill of HIV PrEP (co-formulated tenofovir disoproxil fumarate and emtricitabine). The only two men in the study group to become infected with HIV had been non-adherent to PrEP, which is critical for protection.

The study demonstrates how a proactive and highly-coordinated approach implemented by government and health officials can create positive change in such a short space of time.

In a commentary article published in The Lancet, Professor Sheena McCormak, Professor of Clinical Epidemiology at Imperial College, pointed out that it was a challenge to reach all communities; while the reduction in recent HIV infections exceeded 50% in Sydney’s 'gay suburbs' and the rest of NSW, the reduction was only 7.3% in the reportedly non-gay suburbs of the city. ‘Nonetheless, the overall benefit from the introduction of PrEP was impressive,’ she wrote.

One of the study authors, Professor Andrew Grulich, reflected on the study and its relevance to other countries. When speaking to The Guardian Australia, Grulich noted:

“We think our results can be generalized to other countries with similar epidemics, and that’s high-income countries where a large proportion of HIV is in gay and bisexual men.”

Grulich also emphasized the need for a large-scale approach: “States that don’t invest in a community-based response will have more difficulty in achieving high-level uptake... We can’t expect all gay men to suddenly know about this drug and present to a doctor and ask for it.”

Last year, PrEP was reported to be a cost-effective option for the UK. The Australian government began subsidizing PrEP through the Pharmaceutical Benefits Scheme in April this year. 

Reference:

Grulich, A. E., Guy, R., Amin, J., Jin, F., Selvey, C., Holden, J., . . . Parkhill, N. (2018). Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: The EPIC-NSW prospective cohort study. The Lancet HIV. doi:10.1016/s2352-3018(18)30215-7