Should PrEP be rolled out worldwide?
Multiple randomised controlled trials have proven that the use of pre-exposure prophylaxis (PrEP) significantly reduces the risk of HIV among people at risk. Despite its proven efficacy, PrEP is not widely implemented as an HIV prevention tool. With nearly two million new HIV infections last year, it would seem that PrEP is being overlooked, as commented by a group of scientists in last week editions of The Lancet.
The effectiveness of PrEP in key affected populations, including men who have sex with men (MSM), serodiscordant couples and people who inject drugs, has been proven in multiple studies. However global access to PrEP is extremely limited, with the only the USA approving it for use as a prevention strategy.
One of the concerns about the widespread implementation of PrEP is the cost of scale-up. Generic versions of Truvada, the antiretroviral approved for PrEP, is available in many low and middle-income countries. But without additional donor support and new models for the provision of antiretroviral drugs, some countries seeking to expand access to PrEP would have to make unfair trade-offs with other HIV prevention and treatment priorities.
Interestingly, the current dilemma is reminiscent of 15 years ago, when widespread access to antiretroviral treatment (ART) was a point of discussion. During this time many experts were sceptical about this feasibility of global access to ART in relation to the cost effectiveness and the ability of people living with HIV in poorer countries to adhere to treatment. Over the past 15 years, these concerns have proven false, with the global community on track to achieving the goal of providing ART to 15 million people by the end of 2015.
The researchers remarked that the World Health Organisation should take more of a leadership role in the role-out and implementation of PrEP prevention programmes – emphasising explicitly its use among key affected populations. Manufactures of PrEP, governments and drug regulation authorities should also work on speeding up approval for the use of PrEP. Comprehensive strategies need to be developed for introducing PrEP which are integrated into national health plans and adequately funded. Implementation of these programmes should also not come at the expense of other essential HIV or other health programmes. When this is taking into account, PrEP can become as successful as the introduction of worldwide access to ART 15 years ago.