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Clinical Review State of the Art Review

Recent advances in pre-exposure prophylaxis for HIV

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5011 (Published 11 December 2017) Cite this as: BMJ 2017;359:j5011
  1. Monica Desai, consultant epidemiologist1,
  2. Nigel Field, honorary consultant in public health2,
  3. Robert Grant, professor of medicine3,
  4. Sheena McCormack, professor of clinical epidemiology4 5
  1. 1HIV and STI Department, Public Health England, London NW9 5EQ, UK
  2. 2Centre for Molecular Epidemiology and Translational Research, University College London, London WC1E 6BT, UK
  3. 3University of California School of Medicine; Gladstone Institutes; San Francisco AIDS Foundation, San Francisco, CA 94115, USA
  4. 4MRC Clinical Trials Unit, University College London, London
  5. 5Chelsea and Westminster Hospital, London SW10 9BH
  1. Correspondence to: M Desai desai.monica{at}gmail.com

Abstract

Although pre-exposure prophylaxis (PrEP)—the use of antiretroviral drugs by non-infected people to prevent the acquisition of HIV—is a promising preventive option, important public health questions remain. Daily oral emtricitabine (FTC)-tenofovir disoproxil fumarate (TDF) is highly efficacious in preventing the acquisition of HIV in people at risk as a result of a range of different types of sexual exposure. There is good evidence of efficacy in women and men, and when men who have sex with men use event based dosing. Studies have been conducted in several countries and epidemics. Because adherence to this treatment varies greatly there are questions about its public health benefit. Oral FTC-TDF is extremely safe, with minimal impact on kidney, bone, or pregnancy outcomes, and there is no evidence that its effectiveness has been reduced by risk compensation during open label and programmatic follow-up. It is too early to assess the impact of this treatment on the incidence of sexually transmitted infections (STIs) at a population level. Many challenges remain. Access to pre-exposure prophylaxis is limited and disparities exist, including those governed by race and sex. Different pricing and access models need to be explored to avoid further widening inequalities. The optimal combination prevention program needs to be defined, and this will depend on local epidemiology, service provision, and cost effectiveness. This review updates the evidence base for pre-exposure prophylaxis regarding its effectiveness, safety, and risk compensation.

Footnotes

  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: MD conducted the literature review and prepared the first draft of the manuscript. All authors contributed equally and fully to all remaining aspects of this manuscript. SMcC is guarantor.

  • Funding: SMcC was supported by the Medical Research Council (MRC_UU_12023/23).

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: SMcC was the principal investigator and MD the trial physician in the PROUD study, which was funded in part by Gilead, which provided the drugs for free. MD, NF, and SMcC were on the writing group of the UK national pre-exposure prophylaxis guidelines. RG was the principal investigator of the iPrEx study.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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