Prevention Not Cure? Taking Pride in HIV Care

Now dubbed the 'miracle' HIV pill, PrEP poses some provocative questions for the UK. Does this medicine represent sheer liberation for MSM

PrEP (pre-exposure prophylaxis) is the latest hot topic in HIV prevention and care. This is a drug that, if taken prior to exposure will reduce HIV infections by 86%. The only HIV prevention available currently is PEP - post exposure prophylaxis. As its name would suggest, PEP is taken after you've been at risk of contracting HIV - much like the morning after pill. PrEP on the other hand, is taken daily and before exposure - rather like the female contraceptive pill. Those taking PrEP are then protected before, during and after their exposure to the virus. Put simply, at present in the UK we require MSM (men who have sex with men) to firstly put themselves at risk and to then use medicine later to come back from that risk. Protection isn't provided from the get-go.

So could change be on the way? 56 Dean Street, an NHS clinic that's massively leading the way in all things sexual health, has been involved in the PROUD Study - a national study currently looking into PrEP's effectiveness amongst men participating in high-risk sexual practices. The interim results are in and reveal that PrEP offers a major opportunity to curb new HIV infections in MSM in the UK. Exciting. Meanwhile over in the US, the drug used as PrEP, Truvada has been approved and is in use. Although Europe has yet to follow in the States' footsteps in licensing Truvada for PrEP, studies unsurprisingly confirm the acceptability and desire for the drug amongst MSM.

What's holding us back then and what are the wider issues at stake? Well, there are two central ethical implications to consider. Firstly there is the possibility of drug resistance developing either as a result of not taking PrEP correctly each day or as a result of continued use of the drug after the individual becomes infected with HIV. There is also a question as to whether healthy HIV negative people will consistently take a daily pill. The second relates to the possibility of PrEP leading to an increase in unprotected, high risk sex; as PrEP doesn't provide protection from STI's such as syphilis, this is a valid concern. But most of these considerations have not in fact been borne out of trials to date. People who became infected whilst taking PrEP did not develop resistance. Susan Buchbinder, director of Bridge HIV spoke of a PrEP trial in a refreshingly honest way, "PrEP is not a homerun, and not everyone was protected, but the reason why it didn't always work was that people weren't always taking the pill. If you were to take it perfectly every day would it always work? We don't know the answer. Perhaps the financial implications for us a society should speak for themselves then. In the long term, it's far cheaper to give someone PrEP whilst they're engaging in high-risk sex than it is to treat someone for HIV, a treatment that lasts a lifetime.

Now dubbed the 'miracle' HIV pill, PrEP poses some provocative questions for the UK. Does this medicine represent sheer liberation for MSM, akin to that which women felt in the 60s with the introduction of the contraceptive pill, or is it a waste of precious NHS resources to fund - some would argue, encourage, high risk homosexual lifestyles? "There is definitely a generational gap between the MSM who experienced many deaths among their peers, and the new generation for whom HIV does not seem as serious" says Professor Sheena McCormack, lead investigator for the UK Medical Research Councils PROUD Study. She explains, "These results show that MSM who know they are at high risk of HIV are willing to take PrEP and it works incredibly well at preventing HIV infection in the real world... there is now a real prospect of reversing the HIV epidemic in MSM worldwide."

Stay tuned.


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