World AIDS Day: PrEP uptake main hurdle to 2030 eradication goal as Obama unleashes action plan
On Tuesday, people around the world commemorated the 27th World AIDS Day. Media organizations unleashed a bevy of articles outlining the progress that's been made against the disease; hundreds of informative infographics circulated the Web; and lawmakers, heads of state, and advocates across the globe released messages of hope and perseverance.
Social media was inundated with #WAD2015 sign-offs as people from all walks of life weighed in on what is both a global collective action problem as well as an issue that must be addressed on a nation-by-nation basis.
For the most part, the statistics surrounding HIV/AIDS are encouraging: New HIV infections have fallen 35% since 2000 and 13.5 million HIV-infected people worldwide have received antiretroviral treatment.
But it’s not all good news. Despite the fact that the overall rate of infection is falling, it is still rising in adolescent girls in Africa, where AIDS is the number one killer of adolescents between the ages of 15 and 19. Even in the U.S., where approximately 1.2 million are infected with HIV, 45,000 people are still diagnosed with HIV each year.
During a live webcast from the White House on Tuesday, President Obama outlined key national HIV/AIDS strategic goals while reiterating the collaborative commitment to eradication of new HIV infections and AIDS-related deaths by 2030.
Towards that end, he introduced a Federal Action Plan for 2016-2020. The key components of the plan are focused on HIV testing, encouraging adherence and eliminating stigma. In addition, there is an action item that calls for full access to PrEP (pre-exposure prophylaxis) for "those whom it is appropriate and desired."
Major breakthrough, minor uptake
In July 2012, Gilead’s PrEP—once-a-day Truvada (tenofovir/emtricitabane)—was approved by the FDA for the prevention of HIV in at-risk individuals, defined as men who have sex with men (MSM), non-HIV-infected individuals in relationships with HIV-infected individuals (also known as serodiscordant relationships), and those who inject drugs.
Given the clinical evidence showing the PrEP is 92% effective in preventing HIV transmission, there was a great deal of excitement in 2012 about how this easy-to-use, one-pill-per-day regimen could shift statistics in the right direction. Unfortunately, uptake of PrEP has been alarmingly slow, with only 3,200 prescriptions dispensed since approval.
Whether it’s due to stigma or the fact that specialists tend to only see individuals who are already HIV-infected—while primary care physicians (PCPs) do not see prescription of PrEP as their purview—most at-risk individuals are not enjoying the tremendous preventive benefits of PrEP.
That trend, however, may be on the cusp of changing.
PrEP: The patient perspective
Treato, which uses big-data analytics to distill online conversations into insights, tracked 2,500 conversations poz.com, a community of HIV-positive individuals and their partners, as well as realjock.com, a gay health and fitness site. They found that posts disapproving of PrEP have decreased by 80% since summer 2012.
Treato also uncovered a shift in the reasons why people in the poz.com and realjock.com communities would consider using PrEP. Whereas previously, PrEP was largely seen as a way to enjoy condom-less sex, it is now being discussed as another layer of protection. Also, in the early days of PrEP, most people interested in the therapy were in serodiscordant relationships. But that community has now expanded to include a broader cross-section of at-risk individuals.
These findings signal a shift towards greater openness about using PrEP. However, there is also one disturbing data point uncovered by Treato. According to the group's findings, MSMs are less likely to view PrEP favorably—since summer 2012, the number of disapproving posts about PrEP from MSMs have only decreased by 14%.
The physician perspective
A recent poll fielded by SERMO, a global social media network exclusively for doctors, found that physicians are largely positive about PrEP.
Specifically, in a global poll of 2,672 SERMO members, including both PCPs and specialists, 74% of doctors said they think using PrEP is an effective way to reduce HIV infections.
Separately, SERMO found that 91% of 1,249 polled doctors would recommend PrEP to at-risk individuals and 86% would be willing to share information about PrEP with their patients. On the downside, 59% of this group thought that PrEP would lead more people to be less careful when they are sexually active.
Potential PrEP-related challenges
"Right now, we are seeing ample evidence of unsafe practice with the unusual rise in gonorrhea, chlamydia, and syphilis transmission across the United States," said Dr. James Wilson, Associate Research Professor at the University of Nevada-Reno and Director of the Nevada Center for Infectious Disease Forecasting, in an interview with BioPharma Dive.
"The perception that treatment is available for HIV has encouraged a disregard for safe sexual practice, where the presence of treatment actually interferes with our ability to promote prevention of infection in the first place."
Dr. Wilson also said that another potential problem is related to patient adherence. "Patient compliance is crucial with Truvada, as it is with any antimicrobial therapy," he explained. "If patients fail to adhere to the recommended dosing, then over time we certainly could see resistance develop and therefore lose the opportunity that Truvada is providing the community."
Bringing the PrEP message home
What will it take to decrease the number of individuals diagnosed each year—currently 45,000 in the U.S.? It all comes down to prevention. PrEP therapy, along with use of condoms, are the keys to bringing that number down.
Circling back to the uptake issue, it would seem that all of the new data confirming PrEP’s effectiveness in real-world settings would encourage both physicians and at-risk individuals to take another look at this approach.
Now for some solidly good news: Recent data is starting to show a shift in uptake on a community-by-community basis.
For example, in an article published last month in the journal AIDS, researchers reported that the percentage of high-risk MSMs in King County, Washington who had taken PreP or were currently taking it had increased dramatically since 2012. Among this group, uptake rates increased from 5% in 2012 to 31% in 2015. Moreover, the percentage of high-risk MSMs who had heard of PrEP increased from 13% to 86% during the same period.
The same study showed that the percentage of low-risk MSMs taking PrEP remained steady at 1% to 3%—but this was not cause for concern as these individuals are categorized as low-risk. It should be noted that in Washington State, most insurance plans, including Medicaid, pay for PrEP, and the state also supports a PrEP drug-assistance program.
Awareness, awareness, awareness
President Obama’s national commitment to utilizing PrEP as a reliable form of protection against HIV should help ensure that people in other states enjoy the same access afforded individuals who live in Washington state.
But, as Dr. Wilson points out, there is one more piece to this puzzle. "Uptake (or lack thereof) is most likely due to patient education and awareness, as well as patients themselves recognizing and accepting they are at high risk," he said.
"And from the healthcare provider perspective, they need to know which of their patients are indeed at high risk of contracting HIV."