August 31, 2015
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Key barriers block widespread protection with PrEP

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Despite the potential of HIV pre-exposure prophylaxis, several barriers make it ineffective at the individual and population levels, according to researchers at Emory University who have designed a simple care continuum to improve protection.

“Each step of the proposed continuum represents a critical intervention point that demands immediate attention, particularly in geographic areas that have a large burden of HIV and have been slow to implement PrEP, such as Atlanta,” researcher Colleen F. Kelley, MD, MPH, and colleagues wrote.

PrEP can be highly effective in preventing HIV among high-risk men who have sex with men; however, achieving success with PrEP will require covering a substantial number of at-risk individuals, the researchers said. According to current estimates, using PrEP to cover 40% of at-risk MSM will prevent about 25% of new HIV infections; covering 80% of the population will prevent about 40% of new infections.

Carlos del-Rio

Carlos del Rio

To improve PrEP usage, Kelley, along with Carlos del Rio, MD, and colleagues, have proposed the PrEP care continuum — a simple, stepwise framework to achieve HIV prevention with PrEP.

The first two steps are to define the at-risk MSM population and then improve awareness of and willingness to take PrEP among these populations.

Although it has increased during the last several years, PrEP awareness remains low for several reasons, Kenneth H. Mayer, MD, and Douglas S. Krakower, MD, of The Fenway Institute and Harvard Medical School, wrote in an accompanying editorial.

“Social disenfranchisement plays a role, ie, MSM who are poorer or less educated appear to be less informed about PrEP,” they wrote. “Medical mistrust remains entrenched for some black persons because of earlier adverse experiences with clinical research (eg, the Tuskegee experiment) leading to tuning out new information.”

The third step states that at-risk populations need better access to health care in terms of regular, lower-cost doctor visits, according to Kelley and colleagues.

Fourth, once the patient has a regular provider, that provider must be willing to prescribe PrEP, and finally, at-risk individuals must know that adherence is critical to clinical effectiveness.

In applying their PrEP care continuum to a cohort of MSM in Atlanta, Kelley and colleagues found that, given the barriers currently in place, only 15% of MSM were projected to achieve protection from HIV.

“With substantial 20% increases at all steps, the potential for increasing overall coverage was improved to 44%, which has been projected to avert nearly 25% of new infections over 10 years,” the researchers wrote. “Given the current state of the PrEP care continuum, large, sustained changes are needed to achieve levels of HIV protection that might alter the course of the epidemic.”

Novel strategies are needed to remove the current barriers, they said, and should include free or low-cost open access PrEP programs aimed at high-risk populations. – by Colleen Owens

Disclosure: The researchers report no relevant financial disclosures. Mayer reports receiving unrestricted project support from Gilead Sciences and Merck. Krakower reports receiving unrestricted project support from Gilead Science and Bristol Myers Squibb.