Dr. Nastassia Rambarran is a Guyanese Public Health Consultant, Researcher and Physician living in Barbados. She holds a Medical Degree from the University of Guyana and a Master’s in Public Health from the London School of Hygiene and Tropical Medicine. She is the Public Health Consultant at Guyana’s Society Against Sexual Orientation Discrimination (SASOD Guyana) and site physician providing PrEP at Equals in Barbados.
HIV Pre-Exposure Prophylaxis (PrEP) uses antiretroviral drugs taken as a tablet to prevent HIV infection when persons are exposed to the virus. Studies in 5 continents with over 20,000 persons have shown that PrEP can prevent HIV infection almost 100% of the time if taken consistently, and that it is well tolerated, has very few significant side-effects, and is safe for use in pregnancy or breast-feeding. There was concern early on that persons would take the tablet sporadically, possibly leading to resistance of the virus to the medication in the tablet. “Demonstration projects” which studied the use of PrEP in real-life settings have shown that these concerns have been unfounded – persons are highly adherent to the medication and development of resistance is rare, occurring almost only in persons who were already infected prior to starting PrEP. In addition to the obvious public health utility of PrEP helping to decrease HIV infection rates, there are other direct benefits to users, who report that using the medication increases communication, discussions on safer sex, trust, sexual pleasure and intimacy, and decreases anxiety.
PrEP has been approved in the US since 2012 and was recommended for use in all persons at substantial risk for HIV by the World Health Organization (WHO) in 2015. But in spite of the recommendations and the clear advantages, PrEP use was slow to catch on; partly because the scientific studies needed confirmation from real-life implementation, partly because of huge push-back in the US against the pharmaceutical company making the drug, and partly because of stigmatization and the messaging around the use of the medication, where it was associated with only gay men and HIV (even though to start PrEP persons have to be HIV negative). Most of these challenges have been overcome in the early-adopting countries and use of the medication is expanding and showing impact. According to the latest information from PrEPWatch, almost half a million persons worldwide are currently on PrEP, mostly in North America and Africa. The impact on big cities has been significant, with cases of new HIV infections being halved and clinics reporting many months with almost no new HIV diagnoses.
Use of PrEP in the Caribbean and Latin America has been lagging even longer. In the Caribbean, Barbados and The Bahamas are the only two countries where the measure has been rolled out on a national scale, although several other countries are using it in a more restricted fashion, such as only giving it to the HIV negative partners of persons living with HIV. Given that the safety and effectiveness of the medication are now undoubtable, the challenges facing implementation in the region seem to be: lack of awareness in general and especially in persons who can most benefit from it; and concerns about cost, and increase in risky sexual behaviour on the part of policy makers and health care providers. Stigmatization of the medication, as well as stigmatization within the healthcare system, potentially hampering access for those key populations at substantial risk of HIV (men who have sex with men, transgender persons and female sex workers) is also another challenge. Enough is known about PrEP that large-scale, as well as targeted, awareness campaigns highlighting the safety, effectiveness, need for adherence and medical monitoring required, can easily overcome the awareness barrier. Emphasizing that PrEP prevents HIV can help reduce the stigmatization of the medication. Dr. Jared Baeten in his well-attended presentation at last year’s AIDS conference in Amsterdam, highlighted that PrEP has been shown to work, and seems to work best when it’s easy to access, with few blood tests and utilises a general population approach. This general population approach means that the central recommendation of the WHO is upheld and that PrEP is provided to all persons at substantial risk of HIV infection and not just key populations. In fact, the Barbados guidelines which are based on WHO and US Centers for Disease Control (CDC) guidance, states that one of the groups eligible for PrEP include anyone who, within the last 6 months, has had unprotected sex with 1 or more partners of unknown HIV status who are known, or believed, to be at substantial risk of HIV infection. As you can imagine, this could potentially cover a wide swath of persons, regardless of sexual orientation or gender identity. Using a general population approach also means that PrEP is provided in general settings, such as family planning clinics, community-based centres, at general testing centres or integrated into regular medical services. In an assessment conducted by SASOD Guyana last year, key populations themselves concurred with this approach and even took it one step further, saying that PrEP sounded like something that should be used by anyone who was sexually active and wanted protection from HIV! This approach reduces some of the stigmatization associated with PrEP as well, because it would not only be targeting key populations.
The issue of costing for PrEP has been a thorny one. The costing implications bear some similarity to those cited for the “treat all” policy, to which there was much initial resistance, partly on the basis that it would cost more to put everyone on HIV treatment as soon as they are diagnosed. The fact that a person who is started on treatment right away has a greatly reduced chance of transmitting the virus, decreasing overall rates in the long term, eventually gained traction and has led to the adoption of the “treat-all” approaches in many countries, including Guyana. There is the commonly held perception that the PrEP medication is extremely expensive. This perception likely comes from the US where indeed, the cost of PrEP (as well as almost every other medication for any condition), is sky-high. Notwithstanding this, insurance companies in the US recognized early on that the cost of supplying PrEP was still much lower than providing HIV treatment for life, and so had offered coverage for the medication in many instances. Fortunately, the cost of both brand-name PrEP (Truvada®) and the generic version is markedly lower in the Latin American and Caribbean region than in North American locations, costing as low as USD$70 for a year’s supply for one person. Cost-effectiveness studies from many countries have shown time and again that PrEP is not only a cost-effective tool but also becomes cost-saving in the long run. Every country has a different picture when it comes to HIV, so it’s up to each country to see how best PrEP can be fitted into their budget, bearing in mind that the medication used is already one that is being purchased anyway and already ‘in the system’ (the PrEP medication is currently used in conjunction with other antiretrovirals as HIV treatment), that the medication costs very little in the Caribbean, and with an eye on the long-term overall cost reduction from fewer new HIV infections. It’s worth remembering that PrEP is not a medication that is taken for life, or even for a very long time. It’s intended to be used for a ‘season of risk’ where the person is at high risk of infection. Circumstances change throughout life and some people would only need PrEP for a few months, whilst others may need it for a few years. The cost of prevention through an almost 100% effective method, like PrEP, trumps the cost of a lifetime of HIV treatment any day.
Finally, there is the fear that offering PrEP will result in more risky behaviours – persons will abandon condoms, sexually transmitted infections (STIs) will soar, lots of sex will be had. This last possibility is especially unacceptable to some. To address this, we only have to turn to the research and to a bit of common sense. To start off, every guideline underscores the importance of still using condoms when using PrEP, because PrEP does not protect against pregnancy or STIs. Doctors like me continuously stress this to clients when they are placed on PrEP. But one only has to look at the already high rates of STIs and the slowly climbing increase in HIV in Guyana to know that there is already a significant number of people who are not using condoms. It’s not because they don’t know that condoms exist, but for a variety of reasons, are choosing not to use them. These reasons include the little-considered, but important reality, that for some, condoms can interrupt and interfere with pleasure and intimacy. It is often these non-condom users who are looking to go on PrEP, so the case is not that persons on PrEP will abandon condoms – they weren’t using them to start with. Studies have also shown that there’s no significant change in condom use among PrEP users. Routinely testing for STIs at follow-up visits is part of the recommended protocol for persons who are on PrEP, so that even if STI rates should increase, they are being identified and treated in a speedy manner. The moral hand-wringing about an increase in sexual activity if PrEP is introduced is a throwback to when the oral contraceptive pill came on the market. Similar to PrEP, the contraceptive pill only protects against one condition and not against STIs, and similar to PrEP, the thought that it would lead to more sexual freedom (especially in women) was the cause for much concern. Fortunately, we have evolved in our thinking about the place of the pill, and we should see that judgement about what is an appropriate amount of sex, even sex without condoms, has no consideration in whether a safe, effective prevention tool should be introduced.
PrEP in its current form is not perfect – there are investigations into other forms that may be more acceptable than a tablet, for example, an injectable, as well as having formulations with even less possibility of side-effects. But also, PrEP is not reaching the people who most need it. In the US there are significantly fewer black and latin persons on the medication than white persons, and in Guyana, we are being prevented from accessing a valuable tool because the decision makers are not prioritising this prevention tool due to unfounded fears and concerns not backed by science. Public health is the business of preventing disease, not preventing sex, so efforts to find ways to introduce PrEP as soon as possible need to be ramped up. Withholding PrEP is doing nothing to stop persons from having unprotected sex, but having PrEP can do much to prevent new HIV infections; access to this safe, effective, complementary prevention strategy cannot continue to be denied because of vague and judgemental ‘what if’s.