‘PrEP Brazil’ a success for gay men and trans women
Results from Latin America’s first PrEP demonstration project reveal that it is both feasible and effective as an HIV prevention method in the region. Will Brazil’s example pave the way for the rest of the region?
A demonstration project for pre-exposure prophylaxis (PrEP) in Brazil has provided real-world evidence that men who have sex with men (sometimes referred to as MSM) and transgender women could benefit from the ground-breaking HIV prevention tool.
The results, published in the Lancet this month, found PrEP to be effective, well adhered to, and did not result in risk compensation in these two population groups.
‘PrEP Brazil’ assessed the delivery of PrEP (tenofovir and emtricitabine to prevent HIV) over 48-weeks in 450 gay men and transgender women living in Sao Paulo and Rio de Janeiro.
At the start of the study, all participants were HIV-negative and referred to the programme after reporting at-risk sexual activities – defined as having anal sex without a condom, two or more episodes of anal sex with an HIV-infected partner, or a history of sexually transmitted infections (STIs).
Overall, 83% of the participants were retained at week 48, and of this group, three-quarters (74%) had protective drug concentrations consistent with high levels of adherence, meaning they took at least four doses per week. But young MSM of black race, and those with less schooling, were less likely to have protective concentrations at week 48 – suggesting interventions were needed to help these sub-groups more specifically.
While sexual risk behaviour was high for the study participants overall, receptive anal sex without a condom did not change significantly over time – from 45% at enrolment, to 49% at week 48. At the same time the mean number of sexual partners decreased negligably from 11.4 in the previous three months to enrolment, to 8.3 at week 48. Just two people became HIV-positive during the study follow-up, and they had undetectable tenofovir concentrations in their blood.
This underlines the need for increased access to innovative HIV prevention tools, such as PrEP, to keep HIV epidemics at bay among high-risk populations.
Across Latin America, gay men and trans women are consistently higher burdened by HIV than other populations. In an accompanying comment by Jerome Galea, Ricardo Baruch and Brandon Brown, it was noted that HIV prevalence in Mexico was 0.2% for adults in the general population, versus a staggering 17% among MSM and 20% among transgender women. Another example from Peru reveals HIV prevalence in the general population to be 0.3%, and 15% for MSM and 14% for trans woman.
Yet despite the overwhelming evidence in favour of PrEP, few countries in Latin America include it in their national HIV prevention plans. In fact, PrEP Brazil is the first demonstration project to take place in Latin America. But things are looking up, as seven countries in Latin America and the Caribbean have now planned PrEP demonstration studies in 2018 – and there is an active and vocal civil society now advocating for access.
Galea, Baruch and Brown comment, “As countries move forward with PrEP demonstration projects they must ensure that access equity is part of their programmes, otherwise they risk missing the very people who are often the hardest to engage because of the same conditions that make them the most vulnerable to HIV.”
While this study shows that the evidence for PrEP exists – the authors notes that more work is needed to increase and expand PrEP community awareness and uptake, and to develop strategies for adherence support for groups known to be at risk of non-adherence.
They also noted that transgender women should have PrEP demonstration projects more tailored to them – given that just 25 of the study participants were trans.