PrEP on the frontline of HIV
This week, researchers at the Kirby Institute from the University of New South Wales, the Peter Doherty Institute for Infection and Immunity, and the Australian Federation of AIDS Organisations made headlines with their announcement of the “end of AIDS” as a public health issue in Australia. While this is very welcome news, the prevalence of the infection that leads to AIDS – HIV – remains a significant concern. Fortunately, a breakthrough treatment that could halt its spread, and ease tension in the community over stigma associated with HIV, is becoming available.
Ted Cook, of PASH.tm, a sexual health network for trans men, is one of a growing number of Australians receiving the benefits of the new weapon in the fight against HIV – pre-exposure prophylaxis, or PrEP. “PrEP has completely removed any and all anxiety I had about sex,” he says. “I feel that I’ve been liberated from a fear I didn’t realise was even there until it was removed.”
The prescription drugs administered for PrEP treatment were approved by the Therapeutic Goods Administration in May, and PrEP is being heralded as having a “remarkable potential” to help end the HIV epidemic in Australia.
Yet, despite these prospects, PrEP is still facing an array of policy, regulatory and social challenges before its real impact can be felt.
In many ways PrEP works similarly to the contraceptive pill. People who are HIV-negative take a pill named Truvada every day. Truvada interferes with HIV’s ability to copy itself when someone becomes exposed, preventing exposure from becoming an infection.
PrEP was introduced into the United States in 2012 when Truvada was approved by the Food and Drug Administration. Since then the drug has gone through rigorous scientific testing, with the World Health Organisation judging the efficacy of PrEP taken orally as “high”. Many randomised controlled trials of PrEP have reported that it is almost 100 per cent effective in stopping the transmission of HIV when taken daily as prescribed. This has real potential benefits in helping end the HIV epidemic in Australia.
Data from the Kirby Institute has shown a gradual increase in HIV transmissions in Australia since about the mid-2000s. In the past few years more than 1000 Australians have contracted the infection every year. The increase is largely among men who have sex with men, with researchers from the Kirby Institute pointing in particular to a drop in condom use among gay men. While effective treatment programs are ensuring these infections do not progress to the far-deadlier AIDS, HIV still has serious health impacts requiring complex treatment programs. This is why the Australian government’s most recent HIV strategy set an ambitious target of “virtually no new transmissions” by 2020, a target we currently seem a long way from reaching.
While PrEP will not be able to solve this issue by itself, it has the potential to play a crucial role in particular by targeting this high-risk group of men who have sex with men but do not wear condoms. John Manwaring, of the Victorian Aids Council, explains it like this:
“We know that condom use has been very steady over the years, which suggests that there’s a large portion of people who can’t, don’t or won’t use condoms. This [PrEP] is really targeting them and hoping they’ll take it up and that it will further drive down HIV infections.”
The success of this strategy can already be felt through the way the drug has been received by the gay community. PrEP in particular is credited with helping reduce what is known as “HIV anxiety” – a never-ceasing fear of contracting HIV extremely prevalent among men who have sex with men. This anxiety comes from years of fear and stigma that has followed HIV – stigma that both discourages gay men from getting regular testing and treatment, and in turn can inadvertently promote risky behaviours.
The introduction of PrEP seems to be having a major impact on this anxiety. “Andrew”, for example, who has been taking the drug for about a year, has reported similar feelings to Ted Cook. Andrew told me that:
“[Taking PrEP] definitely makes me feel less anxious about sex. Obviously it’s not a panacea for all STIs, but I feel more confident that I’m protecting myself and other people I have sex with.”
Phillip Joffe, chairman of PrEPaccessNOW, shares a similar sentiment:
“Soon after starting to take PrEP I realised that one of the biggest benefits was that I am no longer worried about my HIV status anymore. Knowing that the pills protected me from HIV meant I could be much more comfortable being intimate with HIV positive people.
“There has been far too much stigma attached to being HIV positive and this has divided the gay community. For me, PrEP removes HIV as a concern completely.”
The reduction in sexual anxiety is reported by both those taking PrEP and those living with HIV. As Phillip describes, it is potentially of great importance that PrEP also helps people cross what some call the “sero-divide” – a term derived from serodiscordant, referring to a couple in which one partner is HIV positive and the other is not. The “sero-divide” is the gap between the lived experiences of HIV positive and HIV negative people.
Ted says, “Another side effect is that I feel way more connected to HIV-positive gay men, many of whom take Truvada as part of their treatment regimen. Crossing the sero-divide without any fear at all has been awesome.”
Nic Holas, who lives with HIV and is the co-founder of the Institute of Many, also talks about this potential impact:
“We suddenly have HIV-negative people who can empathise a lot more with the positive experience. Here are people who, like us, have to take pills every day and, like us, have to learn new ways of disclosing their status as an ‘HIV-negative person on PrEP’. Like so many other HIV-positive people they end up becoming field educators, because they’re going out there and listing their PrEP status on their profile, they’re negotiating sex, and in disclosing they’re on PrEP suddenly they have to educate other people they’re engaging with sexually, like we have to do nearly every other day.”
PrEP therefore not only has the potential to help stop HIV transmissions but also works as a tool to bust HIV stigma. The challenge, then, is how to ensure the drug can be accessed by as many people as possible.
Now that Truvada has been approved by the Therapeutic Goods Administration, it is being considered for subsidy under the Pharmaceutical Benefits Scheme (PBS). While the first PBS meeting to discuss the drug was reportedly planned for this month – the exact date is not made public – there is every chance the listing of Truvada could be rejected or take a number of years to be approved.
The drug is now available in Australia, though it costs about $1000 a month. Many people are therefore importing cheap generics of Truvada from overseas, though this still costs up to $100 a month.
A number of Australian states have also developed free trials for Truvada, providing at-risk people with access to the medication, alongside regular doctor support. These trials are being expanded in many states, with both NSW and Victoria significantly increasing their numbers of trial sites.
While beneficial, these trials will obviously have limited reach. Recruits will largely come through already existent HIV and gay networks. Some research suggests that among the most at risk groups in Australia, these trials will still be short some 3000 places. This naturally severely limits the ability of the trials to have a broad-ranging effect across the community.
With this in mind, HIV-advocacy groups are calling for the listing of Truvada on the PBS as soon as possible. These groups are already engaging in large-scale education and support programs for those who want to take the drug, but until it is widely, and cheaply, available this will have limited impact.
With PrEP offering the potential to play a leading role not just in reducing transmissions but eliminating stigma towards HIV, it’s easy to see why advocates argue that ensuring everyone has equal access to the drug is an essential part of tackling the HIV epidemic.
This article was first published in the print edition of The Saturday Paper on Jul 16, 2016 as "Be PrEPared". Subscribe here.