HIV prevention drug could be hindered by slow roll out

New research, published in today’s New Zealand Medical Journal, praises the benefits of HIV pre-exposure prophylaxis (PrEP) medication, but questions the number of barriers to getting it into the right hands.

On 1 March 2018 New Zealand became one of the first countries internationally to publicly fund PrEP. Eligible people include gay and bisexual men (GBM) and transgender people at high risk, and the partners of people living with HIV. PrEP reduces the risk of contracting HIV by about 86 per cent in GBM individuals, with correct daily timing of the medication that protection can rise to 99 per cent.

Overseas figures are already showing the effectiveness of PrEP, with New South Wales recording a 29 per cent reduction in in HIV cases. London reported a 32 per cent decline in recent HIV cases after implementing large scale PrEP services.

In the article: “Implementing HIV pre-exposure prophylaxis (PrEP): Let’s not get caught with our pants down”, lead author Dr Peter Saxton of the University of Auckland says while PrEP may be the latest HIV prevention technology, it is unfamiliar to most health practitioners in New Zealand.

“New Zealand was quick off the mark to fund PrEP. Now we’re looking to GPs and to DHBs to seize the opportunity and help reverse the HIV epidemic. They play a critical role getting PrEP to individuals in their communities at highest HIV risk before they’re exposed.”

Dr Saxton and study co–authors, including the New Zealand AIDS Foundation, and Auckland Sexual Health Service, say the barriers include low awareness of PrEP among the community and GPs. A slow PrEP roll-out will mean fewer HIV cases prevented.

“PrEP is a hugely promising new tool in the HIV prevention toolkit but it won’t stop transmission if it’s sitting on the shelf.”

“Our concern is that people most at risk of HIV haven’t heard about PrEP; sexual health clinics are struggling from underfunding and don’t have capacity; GPs aren’t offering PrEP to their eligible patients; and we aren’t monitoring PrEP roll-out well enough,” he says.

They also cite new estimates that 5,816 individuals could be eligible for PrEP under the highly targeted publicly funded programme. Since PrEP requires a screening visit and 3-monthly follow-up appointments, that number translates to roughly 29,000 annual clinic encounters nationwide. Half of these would be in Auckland.

“Such numbers are well beyond current sexual health service capacity, meaning PrEP delivery in primary care is crucial to meeting these scale-up targets.”

Dr Saxton says another hurdle facing PrEP roll-out is that many GPs don’t know who their gay and bisexual male patients are, or how to raise sexual health issues.

“GPs obviously don’t want their patients contracting HIV. But many struggle to offer prevention advice because there are few opportunities to improve their training in sexuality and in sexual health.”

“Now that PrEP can be prescribed, it could in fact trigger a revolution in primary care for the gay community and for sexual health. There are plenty of opportunities for innovation in GP practices and plenty of New Zealanders wanting providers who offer safe, relevant and timely healthcare.”

Previous research by University of Auckland authors Peter Saxton and Adrian Ludlam found that only half of gay and bisexual men had disclosed their sexuality to their GP.

Having recently returned from the 2018 International AIDS Conference in Amsterdam, Dr Saxton says that PrEP, alongside condom use, regular HIV and sexually transmitted infection (STI) screening, and prompt treatment for people living with HIV are key to reducing HIV transmission in concentrated epidemics like New Zealand.

“HIV transmission is still too high in New Zealand so implementing PrEP early and fully is critical.” said Saxton.

Notes for editor:
“Implementing HIV pre-exposure prophylaxis (PrEP): Let’s not get caught with our pants down” NZMJ, Vol 131 No 1481 31 August 2018.
Peter J Saxton, Massimo Giola, Edward P Coughlan, Joseph G Rich, Sunita Azariah, Adrian H Ludlam, Christy O’Toole, Mike Pohl, Jason M Myers