PRE-EXPOSURE PROPHYLAXIS FOR HIV PREVENTION: MOVING TOWARD IMPLEMENTATION
Pre-exposure prophylaxis for HIV prevention:Moving toward implementation
Sean Cahill, PhD
Initial results from clinical prevention trials of pre-exposurechemoprophylaxis (PrEP) indicate that PrEP could be a key part of the“game changer” needed to more effectively fight HIV. PrEP entails thatat risk HIV-uninfected people take antiretroviral medications to preventHIV transmission through unprotected sex or sharing needles. Oral PrEPuses antiretroviral medications that are currently available for treatment.A related experimental technology involves topical microbicides, a termthat can refer to any anti-infective agent, but in the current usage refersto topical gels that contain anti-retroviral medications that are appliedvaginally or rectally to prevent HIV transmission. Future approaches tothe use of antiretrovirals for prevention include the use of intravaginalrings or injectable medication.Some oral PrEP and topical microbicide trials have shown promise,while others have not. The use of pre-exposure prophylaxis (PrEP) forHIV prevention has shown efficacy with men who have sex with men (MSM) and heterosexuals. Biomedicalprevention interventions such as PrEP have great potential, especially if coupled with expanded testing,diagnosis, and linkage to earlier initiation of treatment and care (TLC+). Modeling demonstrates the mosteffective deployment of PrEP to slow the spread of HIV will be in combination with scaled-up treatment.PrEP must be accompanied by sustained care and behavioral interventions to ensure adherence, minimizerisk compensation (people increasing risk because of anticipated protection), and monitor side effects anddrug toxicities. Because many people who are at greatest risk to acquire HIV do not access regular clinicalcare, alternative implementation arrangements will be necessary. National monitoring systems are critical topreventing the spread of drug-resistant HIV.Some have raised concerns about PrEP related to potential side effects, risk compensation (the ideathat people will stop using condoms if PrEP becomes available), drug resistance, and cost. However, reviewsof five major clinical trials involving about 6,000 participants by the Forum for Collaborative HIV Researchshows no greater risk of side effects, no risk compensation, and no clinically significant development of drugresistance in participants.
PrEP could be a key part othe “game changer” neededto more eectively ght HIV.