Preventing HIV Infection Pre Exposure Prophylaxis PrEP

Abstract
In recent times, there have been coordinated efforts across the world to rein in new HIV infections. It should, however, be noted that despite the said efforts, HIV continues to be a major health concern across the globe. Further, it should also be noted that the decline in new HIV infections across the globe has decreased minimally over the last one decade. This is an indication of the need for further assessment and evaluation of the various prevention approaches that have been put in place over the last few years. In essence, this text concerns itself with pre-exposure prophylaxis (PrEP) with reference to the prevention of HIV amongst those with substantial risk of contracting HIV – specifically sex workers. PrEP remains one of the HIV prevention measures whose evaluation has indicated significant protection rates in not only real-life, but also clinical trials.
Pre-Exposure Prophylaxis to Prevent HIV Infection
Current statistics indicate that HIV is still a serious global public health concern. This is more so the case given that recent estimates indicate that as of the year 2017, approximately 37 million people from across the world were living with the disease (Avert, 2018). It is important to note that a quarter of the 37 million persons were not aware of their HIV status. Some of the basic measures that have been implemented in the past in an attempt to rein in HIV include, but they are not limited to, the utilization of condoms, limiting of the number of persons one has sex with, and undertaking a HIV test with one’s partner prior to having sex. However, in recent times, PrEP has emerged as a valid HIV prevention option especially for persons whose risk of infection is deemed to be relatively high. The relevance of this prevention approach cannot be overstated given the “renewed concern that the annual number of new infections among adults has remained static in recent years”, with new infections from across the world having “declined by just 18% in the past seven years, from 2.2 million in 2010 to 1.8 million in 2017” (Avert, 2018).
Background
Pre-exposure prophylaxis (PrEP) does not have an assigned definition. In that regard, therefore, no standard definition of PrEP has been offered over time. However, a deconstruction of the three words that make up the phrase (i.e. pre, exposure, and prophylaxis) clearly indicated the nature of PrEP. While pre means prior (or before), exposure is used to denote the action of being subjected to or being vulnerable to something (in this case the HIV virus). Lastly, prophylaxis could be defined as the course of action (i.e. treatment) taken with an aim of preventing disease. Therefore, in essence, PrEP “is a daily course of antiretroviral drugs (ARVs) that can protect HIV-negative people from HIV before the potential exposure to the virus” (Avert, 2018). This is the definition of PrEP that will be adopted in this text.
It should be noted that studies conducted in the past have clearly indicated that when taken on a regular basis and as directed, PrEP happens to be “very effective and reduces the chances of HIV infection to near-zero” (Avert, 2018). It is for this reason that PrEP have variously been referred to as the most promising approach to HIV tackle at present (Drowos, 2019). It should, however, be noted that global efforts to minimize the HIV burden ought to be founded on the analysis of the most prudent delivery avenues that would yield maximum impact among those with substantial risk of contracting HIV – specifically sex workers. This is more so the case given that PrEP is essentially a HIV prevention approach that only works for persons who are HIV negative and are on PrEP prior to their exposure to the virus. For this reason, the discovery/discernment of persons at the highest risk of acquiring HIV and, thus, for whom PrEP would be the most ideal prevention alternative is key. According to the Centers for Disease Control and Prevention - CDC (2019), “a combination of two HIV medicines (tenofovir and emtricitabine), sold under the name Truvada®, is approved for daily use as PrEP to help prevent an HIV-negative person from getting HIV from a sexual or injection-drug-using partner who’s positive.” As CDC further points out, numerous research studies have in the past clearly indicated that when used as directed, PrEP happens to be very effective. Its effectiveness, however, dramatically reduces when it is not taken as prescribed.
Literature Review
In the U.S. alone, there are approximately 1.2 million people living with HIV - with more than 38,000 new infections having been reported in 2006 alone (Drowos, 2019). On the other hand, in the U.K., it is estimated that a minimum of 100,000 are living with HIV (The Converstion, 2018). In 2018, the U.K. reported a total of 6,000 new infections (The Conversation, 2018). This is the clearest indicator yet of the need for a more definitive strategy in seeking to rein new HIV infection rates – particularly given the fact that HIV “infection continues to spread worldwide, negating the very real advances in treatment” (Saloman, 2018). As a matter of fact, “with no cure or vaccine against HIV, these figures clearly highlight the need for new strategies to control transmission” (The Conversation, 2018). So far, PrEP is promising to be quite effective in the containment of new HIV infections. However, various reports have recommended the incorporation of PrEP as part and parcel of other HIV prevention packages. Indeed, as Suraratdecha et al. (2018) observe, the World Health Organisation - WHO has in the past pointed out that PrEP ought to be implemented as part of other intervention measures “including HIV testing, counseling, condoms, antiretroviral therapy (ART) for partners of people living with HIV, voluntary medical male circumcision and harm reduction interventions for people who use drugs” (Drowos, 2019). They, therefore, should not be seen as stand-alone intervention in the war against HIV. Further, despite being effective in the prevention of HIV if used as prescribed, PrEP provides no protection whatsoever against other sexually transmitted diseases such as Gonorrhea and Syphilis.
Effectively, “PrEP has been shown to reduce the risk of HIV infection from unprotected sex by over 90%, and from injecting drugs by more than 70%” (Avert, 2018). This is an impressive record by any standards. However, according to Rosa (2018), there are various aspects of PrEP that are still controversial. The said concerns are inclusive of; the amount of time it takes for PrEP to be effective, the safety of PrEP during pregnancy, the unaffordability of PrEP, etc. Most of the concerns raised in this case are largely triggered by lack of insufficient knowledge or info on how PrEP actually works. Despite these controversies, the only thing that has consistently stood out is the fact that “when drug levels in the blood are high, PrEP offers elevated and consistent protection against HIV” (Rosa, 2018).
It is important to note that when it comes to new HIV infections, there happens to be no uniform geographical distribution of the said new infections. Thus as it has been pointed out elsewhere in this text, the basis of global effort to prevent new HIV infections using PrEP ought to focus on the delivery avenues considered to be most effective and thus likely to have maximum impact. In seeking to define the population at substantial risk of contracting HIV, there is need to first define substantial risk. In this context, substantial risk is defined by the World Health Organization - WHO (2018) “as HIV incidence greater than 3 per cent 100 person-years in the absence of PrEP.” The Centers for Disease Control and Prevention (CDC) also highlights some of the factors that could be utilized in the categorization of persons deemed to be at a higher risk of contracting HIV. According to CDC (2019), in relation to sexual transmission of HIV, those at substantial risk are inclusive of: persons having an active sexual relationship with a HIV positive partner; gay or bisexual persons who have within a period of six months been diagnosed with a sexually transmitted disease, and routinely have anal sex without utilizing a condom; and heterosexual men and women who regularly have unprotected sex with multiple partners whose HIV status is unknown. On the other hand, in relation to transmission as a consequence of illegal drug use, those at substantial risk of acquiring HIV include; persons who use shared injection devices/equipment. The categorizations of substantial risk highlighted above would come in handy in seeking to develop the appropriate PrEP prioritization strategy.
In essence, “the cost of PrEP is an important concern, even in high-income countries” (Avert, 2018). As a matter of fact, various surveys have indicated that one of the key factors working against the implementation of PrEP is its cost (Avert, 2018). This is a concern shared by Suraratdecha et al. (2018) who point out that “PrEP drug costs will continue to pose budgeting challenge…” specifically for developing nations such as Thailand. It is, however, important to note that when highlighted from another perspective, the costs of PrEP drugs appear lower than those of HIV treatment (Avert, 2017). According to Avert (2018), this is not only true per PrEP drug dose, but also over long periods of time. It would also be prudent to mention some of the side effects that have been associated with PrEP. Towards this end, it should be noted that generally, Truvada® has been indicated to be not only well-tolerated, but also safe. This effectively means that most of those who use the same will most likely not experience any side effects. It is however important to note that in clinical trials, some side effects have been reported. To begin with, Drowos (2019) points out that the use of Truvada® has been associated with weight loss, headaches, and nausea. In one particular study, Truvada® users reported a 2.2% weight loss. In the very same study, placebo users reported a 1.1% weight gain. It is also important to note that hepatitis B patients have reported worsening symptoms following administration of PrEP (The Conversation, 2018).
Interventions
According to Avert (2018), in comparison to the general population, sex workers have a significantly high risk of contracting HIV. By some estimates, their risk happens to be as high as 13 times when compared to that of the general population (Avert, 2018). This increased risk profile is often as a consequence of a myriad of factors – and not just a single factor. For instance, in addition to being in a weaker position when it comes to negotiations on safe sex, sex workers are often economically vulnerable (Avert, 2018). The situation is further worsened by the obvious risk of having numerous sex partners. With this in mind, there exists a need to put in place measures to ensure that sex workers benefit from PrEP. This is more so the case with regard to access and cost.
Access: Access to PrEP happens to be severely limited across the board. Thus, those who mostly need it may encounter significant challenges it its acquisition. In essence, “only less than 5% of people at substantial risk of HIV infection” a can be able to access PrEP” (Avert, 2018). In this case, there are various approaches that could be undertaken in an attempt to improve access. One such approach involves permitting persons in need of PrEP to order for the same through a dedicated phone app (Avert, 2018). Given that this would effectively eliminate the need to see a doctor, it could see more sex workers gain access to the relevant drugs.
Cost: It should be noted that in seeking to ensure that the utilization of PrEP amongst those at substantial risk of contracting HIV is not impeded by cost, the relevance of health insurance cannot be overstated. More specifically, in the U.S., health insurance companies do fill prescriptions for the drugs. By some estimates, without insurance, PrEP costs could be in excess of $10,000 per annum (Drowos, 2019). It is also important to note that Medicaid coverage in this case happens to be different in various states. At present PrEP is covered by Medicaid in states such as Florida and New York. For those persons who do not have private health insurance, there are various alternatives that they could explore so as to access PrEP at cheaper prices. These include, but they are not limited to; clinical trials and Gilead’s prescription assistance programs.
In seeking to further enhance the uptake as well as adherence to PrEP in this category, we ought to heed to two lessons from South Africa’s oral PrEP rollout for sex workers. As WHO (2018) observes, there happens to be a strong correlation between the effectiveness of PrEP in the prevention of HIV and adherence to the same. As a matter of fact, “the main predictor of the effectiveness of PrEP is adherence” (Fadul, 2016). A recent study indicates that “participants who engaged with daily administration only 50% of the time, had a 50% reduction in the efficacy of protection” (The Conversation, 2018). Towards this end, according to Bhavaraju and Uribe (2019), there is need to meet sex workers at their work stations so as to guarantee both access and uptake. This could be inclusive of visiting sex workers in brothels and restocking their PrEP as well as other relevant essentials such as condoms and HIV test kits. The other approach involves the establishment of a network of support services involving peer educators, counselors, etc. This provides sex workers with a point of reference with regard to their most pressing concerns.
Conclusion
Global efforts to minimize the HIV burden ought to be founded on the analysis of the most prudent delivery avenues that would yield maximum impact. In the final analysis, it should be noted that PrEP ought to be seen as an additional tool in the war against HIV and not as the only option in efforts to contain new infection rates – particularly amongst those with substantial risk of contracting HIV. As it has been indicated above, PrEP is not 100 effective in the prevention of HIV. Further, it does not in any way provide a cure for the HIV virus. For this reason, to definitively win the war against HIV, there is need to combine PrEP with other HIV prevention efforts, i.e. safe sex practice. If this is done, then PrEP will be a true game changer as far as our approach to the prevention of HIV is concerned.




References
Avert (2018). Global HIV and Aids Statistics. Retrieved from https://www.avert.org/global-hiv-and-aids-statistics
Avert (2018). Pre-exposure Prophylaxis (Prep) for HIV Prevention. Retrieved from https://www.avert.org/professionals/hiv-programming/prevention/pre-exposure-prophylaxis
Bhavaraju, N. & Uribe, D. (2019). Early Lessons from South Africa’s Rollout of Oral PrEP to Sex Workers. Retrieved from https://www.prepwatch.org/early-lessons-south-africa-rollout/
Centers for Disease Control and Prevention - CDC (2019). HIV Prevention: PeEP and PEP. Retrieved from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/HIVprevention.html#risk
Drowos, J. (2019). Primary Care: Clinics in Office Practice - Prevention and Screening. New York, NY: Elsevier Health Sciences.
Rosa, K. (2018). Separating Fact from Fiction: 7 Controversies Surrounding PrEP. Retrieved from https://www.contagionlive.com/news/separating-fact-from-fiction-7-controversies-surrounding-prep
The Conversation (2018). Why a Pill to Prevent HIV is Causing Great Controversy. Retrieved from https://theconversation.com/why-a-pill-to-prevent-hiv-is-causing-great-controversy-35052
Saloman, L. (2018). A Cure for HIV? An Update One Year Later. Retrieved from https://www.contagionlive.com/publications/contagion/2017/may2017/how-close-are-we-to-a-cure-for-hiv
Suraratdecha et al. (2018). Cost and Cost?Effectiveness Analysis of Pre?Exposure Prophylaxis among Men Who Have Sex with Men in Two Hospitals in Thailand. Journal of the International AIDS Society, 21(5), 171-178.
World Health Organization – WHO (2018). WHO Recommendation on Pre-Exposure Prophylaxis for HIV Prevention. Retrieved from https://extranet.who.int/rhl/topics/hiv-aids/who-recommendation-pre-exposure-prophylaxis-hiv-prevention