Gay health groups cautiously welcome news of PrEP as-needed dosage

HIV and AIDS organisations in Australia have cautiously welcomed new evidence from Europe that PrEP as a HIV prevention method can be undertaken on an as-needed basis, rather than a permanent drug regime.

As reported in AIDS Map recently, a second scientific trial of PrEP — or pre-exposure prophylaxis — by French AIDS research organisation IPERGAY not only confirmed that it could be highly effective, but its intermittent, on-demand regimen test was also effective.

In the trial, participants did not take PrEP daily, but only when they anticipated having sex. The regimen saw them taking two pills of Truvada in the 24-hour period before anticipated sex, and if it happened, two separate one-pill doses in the two days afterwards.

Further trials will reportedly continue for at least a year to not only demonstrate that “on demand” PrEP can have long-term benefit but also to gather safety data.

“The biomedical concept of on-demand PrEP at the time of sexual exposure, in a broader prevention framework, is validated,” principal investigator Professor Jean-Michel Molina told AIDS Map, before adding that condoms remained the “cornerstone” of HIV prevention.

Director of fellow French AIDS organisation ANRS Professor Jean-François Delfraissy hailed the trial results as a “major breakthrough” in the fight against HIV.

“The results of the… trial should change national and international recommendations for HIV prevention,” he said.

Australia’s national umbrella group of AIDS and LGBTI health promotion organisations, Australian Federation of AIDS Organisations (AFAO), said the IPERGAY results were an “exciting new development”.

“Some people may find adhering to a daily regimen a challenge and these results provide another alternative,” AFAO’s Health Promotion Program acting manager Sean Slavin said.

“Using PrEP shouldn’t be construed as dependence on medication. It is one HIV prevention strategy that some gay men may take up at certain times in their lives. Other strategies may come into play at other times.”

Meanwhile, ACON chief executive Nic Parkhill and Victorian AIDS Council (VAC) chief executive Simon Ruth welcomed the development with more caution, both highlighting the need to see the complete data from the study.

“While the trials were stopped early due to obvious efficacy over no PrEP, we still don’t know the extent of the reduction in risk or the level of confidence in those results,” Parkhill said.

“But if these are strong results, then we would expect this mode of taking the drug could allay that concern for many gay men. In a nutshell, it’s all going to depend on the level of risk reduction and what each individual is going to think acceptable.”

Ruth agreed: “It is obvious that PrEP is going to be an important part of HIV prevention and we need as much information as possible on its use and acceptability in the community… If the IPERGAY study pans out, it will mean PrEP is not a lifelong commitment and it make it much more cost effective.”

The local organisations also dismissed the notion that the latest evidence could decouple PrEP community debate rooted in identity politics, such as “whores” who are on PrEP and “prudes” who aren’t, as they believed this was more prevalent in the US.

“There has been an unfortunate moralising in some of the PrEP discussion in the United States,” Slavin said.

“Fortunately, we have not seen this in Australia where the community response to HIV has always incorporated a positive and affirming approach to sex and sexuality.”

Ruth echoed the sentiments.

“Ultimately, what gay men taking PrEP are doing is making a responsible, ethical decision to protect themselves against acquiring HIV,” he said.

“They may not take it for the rest of their lives, they may employ other ways to stay safe but if PrEP exists as an effective HIV prevention strategy, then gay men ought to be supported in taking it up. ”

Parkhill believes the debate over PrEP and how it was playing out in Australia is not yet clear, but said he would “expect positioning PrEP as a time-limited, additional precaution men may take ahead of busy times has the potential to better position PrEP as a strategy of responsibility rather than self-indulgence”.

PrEP in Australia is currently only available through two clinical trials, and AFAO, ACON and VAC believe the recent IPERGAY results would help with the case for licensing and subsidising the medications nationwide.

Slavin said AFAO was keen for the situation to be resolved sooner, and it was preferable that PrEP use occurs under proper medical supervision instead of informally, where the drugs are obtained on the internet or elsewhere.

“Until PrEP is formally licensed here it is very difficult for community organisations to offer any advice around its use,” he said.