HIV pre-exposure prophylaxis (PrEP)BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k4681 (Published 17 January 2019) Cite this as: BMJ 2019;364:k4681
All rapid responses
PrEP is a controversial issue. Why should we give an expensive medicine to someone who engages in a risky sexual behavior voluntarily? What if she/he pays for it? As preventive measurement, does it have any negative impact? Should Governments cover these treatments? Using PrEP is a minimizing-the-risk approach instead of recommending safe sex practices. Also the PrEP could send a signal that undervalues safe sex practices.
Society, or some groups of society, are continuously evolving and the Fourth Industrial Revolution is here (1). PrEP is already an option to declare in Social Media and flirting apps so people know about their HIV-status and their willingness to have unprotected sex.
Yes, if we avoid one case, it will save a life long treatment and break a link in the transmission chain of the disease. Therefore, we agree in prevention measures like pre- or postexposure prophylaxis, but safe sexual practices should be the first approach in avoiding HIV; Then, if not possible, the second line approach could be PrEP.
Whether we like it or not, there are plenty of examples of Health Services treating patients who engage in risky behaviours (drugs or unsafe sex practices). Only throughout education we can achieve further goals. However, general practitioners have to take into account this risky behaviours and PrEP could be another opportunity to avoid infection in a harm reduction program (same example as needle exchange program for injecting drug users) (2).
If the Health System doesn't cover this preventive measures, we could be at another example of the Inverse Care Law (3) by protecting less those who actually need more. As Dr Ong et al states in his article: At 86% effectiveness, PrEP given to 5,000 MSM at 3.3 per 100 person-years annual HIV incidence, assuming risk compensation (20% HIV incidence increase), averted 118 HIV infections over remaining lifetimes and was cost saving. Substantially reduced PrEP drug costs are needed to give the necessary assurance of cost-effectiveness, and for an affordable public health programme of sufficient size (4).
We don’t see how this paper promotes the irrational use of Truvada (R) by explaining a patient’s case and the state of the art of PrEP, although we encourage the safe sex practice advice as first line approach.
1. Fourth Industrial Revolution. Wikipedia. 2019.https://en.wikipedia.org/wiki/Fourth_Industrial_Revolution
2. Uyei J, Fiellin DA, Buchelli M, et al. Effects of naloxone distribution alone or in combination with addiction treatment with or without pre-exposure prophylaxis for HIV prevention in people who inject drugs: a cost-effectiveness modelling study. The Lancet Public Health 2017;2. doi:10.1016/s2468-2667(17)30006-3
3. Hart JT. The Inverse Care Law. The Lancet 1971;297:405–12. doi:10.1016/s0140-6736(71)92410-x
4. Ong KJ, Desai S, Field N, et al. Economic evaluation of HIV pre-exposure prophylaxis among men-who-have-sex-with-men in England in 2016. Eurosurveillance 2017;22. doi:10.2807/1560-7917.es.2017.22.42.17-00192
Competing interests: No competing interests
When thinking in PrEP (Truvada) we need to consider:
(1) the drugs are made widely available to those at highest risk;
(2) the drugs are used consistently;
(3) the drugs are provided as part of a comprehensive counseling program, including frequent follow-up testing; and
(4) widespread risk compensation (e.g., decreased condom use or increased numbers of sexual partners) does not occur (1).
For example, in Australia, it has been demonstrated a "risk compensation behaviour": "high medication adherence rates occurring with a decline in condom use and a rise in STIs, suggest that prevention, early detection and treatment of STIs is a chief research priority in the current era of HIV PrEP" (2).
It is also important to comment on the absolute risk reduction:
"In the other 11 trials, the rate of HIV infection ranged from 1.4% to 7.0% over 4 months to 4 years in participants randomized to placebo or no PrEP, and 0% to 5.6% in those randomized to PrEP. In a meta-analysis of these trials, PrEP was associated with reduced risk of HIV infection compared with placebo or no PrEP (relative risk [RR], 0.46 [95% CI 0.33 to 0.66]; absolute risk reduction, -2.0% [95% CI, -2.8% to -1.2%]) after 4 months to 4 years" (3).
So you need to treat 100 persons during one year to avoid 2 cases.
When commenting about harms, you do not consider population harms, as antimicrobial resistance because the increase use of antibiotics to treat the increase STIs incidence.
We need to be very carefully when recommending PrEP. Your paper might promote the irrational use of Truvada
Juan Gérvas, MD, PhD,, retired general practitioner, Equipo CESCA, Madrid, Spain @JuanGrvas firstname.lastname@example.org
Competing interests: No competing interests