For the past few years, the big news about HIV prevention has all centred around a new and sometimes controversial prevention method called Pre-Exposure Prophylaxis, better known as PrEP. This method sees people who do not have HIV take a pill daily to reduce their risk of contracting HIV. The pill is called Truvada and contains two antiviral medicines which are commonly prescribed to HIV positive people to suppress the virus. The treatment is now available in Australia and recent studies have shown extremely promising results that indicate that PrEP, when used properly, is a very effective method of preventing the transmission of HIV. To find out more about PrEP, QNews met with HIV expert and Chair of the HIV Foundation QLD, Dr Darren Russell.
QNews: PrEP has been hailed as a game changer for HIV prevention yet, until recently, it hasn’t seemed to have enjoyed the same type of attention in Australia as it has internationally. Why do think we are lagging behind?
Dr Russell: I think a lot of the studies were done in the United States early on and not really in Australia. In fact, I’m struggling to think about the studies apart from the three demonstration projects in Victoria, New South Wales, Queensland that have been done. So, I think the Americans were off and running with it a bit.
The other thing that America has, although their health system is a bit fragmented, if you’ve got private insurance, you’re able to access the medication, and now, some of the states subsidising it for people so that access is available. I think in Australia, we didn’t do the studies initially, so there wasn’t much awareness of PrEP, and we don’t have a mechanism to pay for it yet in Australia.
While PrEP is not currently on the Pharmaceutical Benefits Scheme (PBS), the treatment is available for people in Australia. Roughly, how much would it cost people wanting to access it?
If you get a prescription and go to your local chemist, they can sell it to you for probably $850 or so a month, which is a lot of money. If, however, you want to get it from overseas, you can import it legally, and that will cost about $105 a month. If you’re employed, $105 a month is doable.
For PrEP to be effective, do people need to be taking it everyday or just in periods where they’re going to be more sexually active?
That’s a good question. The initial studies were all done on people taking it everyday. We knew that if they took at least four tablets a week, they wouldn’t contract HIV, but the tablets they were taking weren’t timed with sex they were having, so you just take it everyday. If you miss one here or there, it didn’t seem to matter, but a French study, called IPERGAY, was just presented a couple of weeks ago in Seattle, and that shows you only need to take four tablets around the time of the sex act. So that’s a bit of a game-changer. That brings the cost down, it’ll make it available to a lot more guys, but we don’t quite know how to roll that out or if we should roll that out yet.
The French study which you just mentioned along with a separate British study released at the same time, coincidentally both showed PrEP reduced HIV transmission by 86%. While this is a high percentage, it still suggests that there’s 14% of people who still contracted HIV. How much confidence should people have in PrEP?
If people take the tablet everyday, the risk of contracting HIV is almost zero. Once you start missing tablets, then the risk can increase. A bit like the contraceptive pill and preventing pregnancy in women. If women take their pill everyday really well, the risk of pregnancy is very low, but if they miss pills here and there, the risk can increase.
With that 86% that you quoted for the PROUD and IPERGAY studies, the people who did contract HIV, and there were two in the treatment arm and the PrEP arm of the IPERGAY study, neither of those guys had the drugs in their system at that visit or the visit before to the doctor, so they weren’t on the tablets. They said to the investigators, “we stopped the drug months ago,” but they’re still included as a failure because they were in the treatment group. Here’s the issue. If you take it properly, it works, nearly 100%. If you don’t, it’s not so good.
HIV medications have long had a bit of a bad rep for nasty side effects. What type of side effects does Truvada generally have on people, particularly, HIV-negative people?
I think that’s a good distinction to make. The side effects it has in HIV-positive people are more than the side effects it has on HIV-negative people. In the French study, they, so far, have seen no difference in the side effects between those in the treatment arm and the control arm. No difference. The English study, the PROUD study, couldn’t show differences either. So, it seems, at least short-term, there are virtually no side effects.
When you speak to the guys in America who are taking it, they do often complain for the first couple of weeks or so of bloating or loose bowel actions or farting, which is not very sociable, but nothing serious. There are longer-term problems with bone density and renal function, kidney function, in people with HIV, but they’re not really showing those up in people without HIV so far.
One of the criticisms of PrEP is that people might use it as a party drug. They might throw away condoms. What are your thoughts on these criticisms?
The studies have shown that, in fact, condom usage has increased a bit in the guys in the studies, but these are guys within a clinical trial, so they’re probably different to a lot of other people. There may be less condom usage. There may be more condom usage.
Some of the guys on PrEP say, actually, they feel they’re taking more responsibility and that they actually feel they should use condoms better than what they were before, which is a bit weird, but other guys do abandon condoms. If they’re taking their PrEP properly, that won’t matter with regards to HIV because they won’t get HIV.
Who should be taking PrEP? Is it for people in serodiscordant relationships? Is it anybody? People who are highly sexually active?
I think if we’re going to market it, we should market it to more sexually active guys and guys who don’t use condoms all the time for whatever reason. When it comes to serodiscordant relationships, if your partner is HIV positive but on treatment and undetectable, the risk of transmission is close to zero. So, it’s not necessary for those people in those relationships. If they want the belt-and-braces approach, they could take it as well to be doubly sure, but it’s probably not necessary.
As we mentioned earlier, PrEP is not available on the PBS. Do you think that will be changing any time soon?
Truvada will come off-patent in a couple of years time and will be much cheaper then. I would like to think the drug could be on the PBS before then, but realistically, I think it’s unlikely. Gilead, the manufacturer of the drug are putting in an application to the Therapeutic Goods Administration to have it registered or approved for PrEP, but they haven’t yet been convinced they should put in an application to the Pharmaceutical Benefits Scheme. We would hope we could turn around their ideas and get them to put that in, but even if they did, it would take a long time.
If any of our readers are interested in starting PrEP, how do they go about it?
If people are interested in starting PrEP, they can contact the HIV Foundation and we’ll put them in touch with our CHEP team who will talk them through it. They can go and see their gay-friendly GP or sexual health clinic. We’ve certainly got a number of people already on PrEP in Queensland, but it’s a pretty small number, and most of those will have got it through a gay-friendly GP or a sexual health clinic.
For more information about PrEP, please visit www.hivfoundation.org.au