PrEP, vaccines, and other ways to deliver drugs to prevent HIV infection were among the highlights of the HIV Research for Prevention conference, or HIVR4P, held last week in Chicago.
Studies have shown that daily Truvada (tenofovir/emtricitabine) pre-exposure prophylaxis reduces the risk of HIV among gay and bi men by more than 90 percent if used consistently. Researchers are both looking at how to expand PrEP access to those who need it most and seeking to develop new prevention tools.
Sharon Hillier, Ph.D., with the Microbicide Trials Network, reviewed several new biomedical prevention methods in the pipeline. These include vaginal rings that dispense antiretroviral drugs (sometimes along with contraceptives), vaginal or rectal films, and a rectal douche containing tenofovir. The douche demonstrated good coverage and protective activity in laboratory and animal studies, but much more research is needed before it's ready for human use.
"We have to remember that making products that work is only half the battle," Hillier said at the conference. "We also have to develop products that are less stigmatizing, that are fun to use, and that don't undermine the sexual experience."
PrEP use in San Francisco
Susan Scheer, Ph.D., of the San Francisco Department of Public Health, presented findings on PrEP knowledge, usage trends, and disparities in the city. Current estimates suggest that approximately 12,500 San Franciscans are now on PrEP.
"Measuring PrEP knowledge and use is difficult," Scheer told the Bay Area Reporter. "People go on and off PrEP, so determining current users is hard. Sites often can only guess at the numbers on PrEP, and some sites can't pull the information from their medical records."
A recent informal survey of major PrEP providers by the B.A.R. estimated that more than 6,000 people in the city are on PrEP, including 1,000 at the San Francisco AIDS Foundation's Magnet program at Strut; 1,800 at Kaiser Permanente San Francisco; over 500 at City Clinic; and about 220 at DPH primary care clinics.
Rather than adding up PrEP users at different sites, Scheer's team relied on surveys asking how many clients of community-based organizations and clinics had used PrEP, and applying this percentage to the total number of at-risk men who have sex with men. The 12,500 figure assumes that 25 percent of an estimated 50,000 HIV-negative gay and bi men in the city use PrEP.
Self-reported data showed that only 19 percent of City Clinic clients knew about PrEP in 2011, the year after publication of trial results showing it is highly effective. By 2016 this had increased to around 90 percent at City Clinic and Strut, but just 71 percent at community HIV testing sites.
Turning to self-reported use, 29 percent of City Clinic clients and 44 percent of Strut clients said they had used PrEP in 2016, but this fell to only 11 percent at community testing sites.
Scheer's report confirmed that gay men of color and women are less likely than white gay men to know about and use PrEP. People under age 18 and over 50 are also less likely to do so.
Although African-Americans accounted for 17 percent of new HIV infections in San Francisco in 2015, the proportion of black PrEP users ranged from less than 5 percent to just over 10 percent at the various sites. Strut and Kaiser were more likely to see white PrEP users, while DPH primary care clinics came closest to having their PrEP users match the racial distribution of new infections in the city �" and were the only sites to serve a substantial number of non-transgender women.
As part of San Francisco's Getting to Zero initiative, DPH aims to increase the number of people on PrEP to 15,000 by 2017, with around 2,500 new PrEP starts next year.
"It is important to monitor PrEP use so that gaps in knowledge and use can be identified and resources can be used to target those not currently being reached," Scheer told the B.A.R. "We want to be a city where everyone who would benefit from PrEP knows about it and has equal and easy access to it."
PrEP 'in the wild'
In contrast to San Francisco and cities such as Boston, Chicago, New York, and Seattle, other parts of the country are not doing as much to expand access to PrEP. Although the South has the highest rate of new HIV infections, public health officials there are doing less to support and promote PrEP.
Dr. Dawn Smith from the Centers for Disease Control and Prevention reported that just 38 percent of health departments nationwide were supporting PrEP �" and often this only involves referring high-risk individuals to PrEP providers, with fewer actively working with providers to improve PrEP delivery or providing and funding it themselves.
Outside the United States only a handful of countries have approved Truvada for PrEP, including Australia, Canada, France, and South Africa. Last week Norway became the first country to announce that it would provide PrEP for free under its national health system.
Lack of PrEP approval in most countries has led a growing number of people to seek access to PrEP "in the wild" outside established health care channels, according to conference presentations and a new report, "PrEP Access in Europe."
People may obtain PrEP, for example, by buying Truvada or generic equivalents online, personally importing it from other countries, or getting it from HIV-positive friends. But this often means forgoing the regular HIV testing and kidney function monitoring needed to use PrEP safely.
"The official authorities are playing catch-up and failing in their duty to protect public health," the report authors wrote.
Med student moralism
Finally, Sarah Calabrese, Ph.D., of Yale University, reported findings from a survey of more than 100 students at two medical schools, showing that ideology and moral judgment may interfere with their ability to provide PrEP.
Surveyed students said they would be less willing to prescribe PrEP to gay men who were non-monogamous and did not use or planned to stop using condoms �" precisely the group most in need of an effective prevention method. They also found it more acceptable to stop using condoms to allow for conception, rather than to improve sexual function or to enhance pleasure or intimacy.
"Providers are gatekeepers," Calabrese said at an HIVR4P press briefing. "Personal values may undermine optimal access to PrEP. Cultural competence training needs to be part of PrEP training."