{"id":1121,"date":"2015-10-22T09:39:39","date_gmt":"2015-10-22T09:39:39","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=1121"},"modified":"2015-10-22T09:39:39","modified_gmt":"2015-10-22T09:39:39","slug":"prep-highly-effective-against-hiv-in-msm-and-has-limited-impact-on-risk-compensation","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2015\/10\/22\/prep-highly-effective-against-hiv-in-msm-and-has-limited-impact-on-risk-compensation\/","title":{"rendered":"PrEP highly effective against HIV in MSM and has limited impact on risk compensation"},"content":{"rendered":"<p>The year 2015 is likely to turn out a decisive one for the story of PrEP (pre-exposure prophylaxis for HIV). \u00a0After a slow and faltering beginning, with trials in sub-Saharan Africa dogged by problems of poor adherence (<a href=\"https:\/\/blogs.bmj.com\/sti\/2013\/11\/21\/partners-prep-sub-study-finds-no-evidence-that-prep-use-is-associated-with-risk-compensation-behaviour\/\">Haberer &amp; Bangsburg\/STI\/blog<\/a>; <a href=\"https:\/\/blogs.bmj.com\/sti\/2014\/11\/13\/failed-prep-trial-voice-participants-give-reasons-for-their-poor-adherence\/\">VOICE D\/STI\/blog<\/a>; <a href=\"https:\/\/blogs.bmj.com\/sti\/2013\/03\/27\/disappointing-tenofovir-prep-trials-maybe-adherence-is-not-to-blame-2\/\">Hendrix &amp; Bumpus\/STI\/blog<\/a>), this intervention appears at last to have proved its worth \u2013 at least in high-risk populations such as MSM in Europe and America.\u00a0 This is to be seen in a succession of results from recent or still ongoing trials.<\/p>\n<p>Following the report of encouraging headline figures at last February\u2019s Conference on Retroviruses and Opportunistic Infections (CROI), the <strong>UK PROUD study<\/strong> (Pre-exposure Option for reducing HIV in the UK immediate or Deferred) has published its results (<a href=\"http:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(15)00056-2\/abstract\">McCormack &amp; Gill<\/a>; <a href=\"https:\/\/blogs.bmj.com\/sti\/2015\/03\/25\/reported-86-effectiveness-for-msm-prep-by-proud-study-makes-this-intervention-a-viable-option-for-uk-health-services\/\">PROUD\/STI\/blog<\/a>).\u00a0 As stated in my earlier blog, this study, based in 13 UK clinics, aimed, in its design, to replicate real-life conditions in being an \u2018open-label\u2019, as opposed to a blind placebo controlled, randomized study.\u00a0 September also saw the publication of a brief report of a<strong> San Francisco based study<\/strong> (<a href=\"http:\/\/cid.oxfordjournals.org\/content\/early\/2015\/09\/24\/cid.civ778.abstract\">Volk &amp; Hare<\/a>) investigating HIV and STI incidence amongst a comparable number of patients (650) referred for PrEP over 2 and a half year period in a clinical practice under the health insurance provider Kaiser Permanente.\u00a0 Finally, the PROUD study refers to the still ongoing <strong>IPERGAY study<\/strong> run by French and Canadian researchers (<a href=\"http:\/\/i-base.info\/ipergay-prep-study-shows-early-efficacy-in-protecting-gay-men-from-hiv\/\">IPERGAY<\/a>; <a href=\"http:\/\/www.croiconference.org\/sessions\/demand-prep-oral-tdf-ftc-msm-results-anrs-ipergay-trial\">Molina &amp; Delfraissy<\/a>).\u00a0 The latter differs from the PROUD study, first in respect to the PrEP regime followed, which is \u2018on demand\u2019 (i.e. before and after sex) rather than daily; second, in having a blind placebo controlled, rather than an \u2018open-label\u2019, design.<\/p>\n<p>The three studies investigate relatively high-risk, largely MSM, populations \u2013 to judge by the high rates (c. 34%-50% within a year of follow-up) of STIs and especially (18%-32%) of rectal STIs.\u00a0 \u00a0Rates of HIV transmission, however, were, in all cases, similarly low.\u00a0 As indicated in my blog (<a href=\"https:\/\/blogs.bmj.com\/sti\/2015\/03\/25\/reported-86-effectiveness-for-msm-prep-by-proud-study-makes-this-intervention-a-viable-option-for-uk-health-services\/\">PROUD\/STI\/blog<\/a>), the PROUD study headlined an HIV incidence of <strong>1-2<\/strong> per 100 person years (py) in the immediate initiation, as against <strong>9<\/strong> per 100 py in the \u2018deferred initiation\u2019 arm.\u00a0 The IPERGAY study saw rates of <strong>0.94<\/strong> as against <strong>6.75<\/strong>.\u00a0 The San Francisco study was without a control arm, but saw <strong>zero<\/strong> cases of HIV among PrEP users over the two and a half year study period.\u00a0 All this would suggest that amongst self-selecting high-risk MSM, PrEP interventions can be successful in preventing HIV transmission.\u00a0 It would, however, be reassuring to know more about the impact of PrEP on <strong>risk compensation<\/strong> \u2013 always the supposed \u2018Achilles heel\u2019 of MSM PrEP (<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/16528088\">Cassell &amp; Halperin<\/a>) \u2013 especially as rates of STI incidence following PrEP initiation were very high in all studies. \u00a0Here the published version of the PROUD study has the advantage of being able to compare incidence of other STIs between the intervention and the control arm of the study. \u00a0No significant difference between the two arms was observed.\u00a0 This was particularly encouraging as the PROUD study was designed to replicate the conditions of a real-life intervention in that those in the intervention arm knew they were taking PrEP, and could have adjusted their behaviour on the basis of this knowledge.<\/p>\n<p>A final issue that PROUD and IPERGAY may begin to help health professionals to address is that of <strong>cost effectiveness<\/strong>.\u00a0 The PROUD researchers calculate that \u2018<strong>thirteen<\/strong> men in a similar population would need access to 1 year of PrEP to avert 1 HIV infection\u2019.\u00a0 This would make PrEP targeted at this group cost-effective at current prices if the cost of tenofovir and emtricitibine were halved.\u00a0 It could also be achieved if the proposed intervention were to adopt the \u2018on demand\u2019 regimen trialled by IPERGAY: \u00a0namely, two tablets 2-24 hrs before sex, one taken 24hr, and a further tablet 48 hrs. after.\u00a0 IPERGAY, it will be remembered, demonstrated the same 86% reduction in HIV incidence that was observed by PROUD.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The year 2015 is likely to turn out a decisive one for the story of PrEP (pre-exposure prophylaxis for HIV). \u00a0After a slow and faltering beginning, with trials in sub-Saharan Africa dogged by problems of poor adherence (Haberer &amp; Bangsburg\/STI\/blog; VOICE D\/STI\/blog; Hendrix &amp; Bumpus\/STI\/blog), this intervention appears at last to have proved its worth [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/sti\/2015\/10\/22\/prep-highly-effective-against-hiv-in-msm-and-has-limited-impact-on-risk-compensation\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2043,2012,2380,4357],"tags":[],"class_list":["post-1121","post","type-post","status-publish","format-standard","hentry","category-behaviour","category-hiv-infection","category-pre-exposure-prophylaxis","category-risk-compensation"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>PrEP highly effective against HIV in MSM and has limited impact on risk compensation - Sexually Transmitted Infections<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" 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