Pre-Exposure Prophylaxis or PrEP

Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. This blog looks at some of the pros and cons of PrEP.

Thursday, November 25, 2010

Is PrEP Destined to Be a Recreational Drug for Westerners?

There's a lot of excitement, not so surprising, about the results of a PrEP trial which took place among gay men and transgender women; it can cut new infections by at least 44%, those carrying out the research say. Thankfully, there are also cautioning voices, suggesting that there is a long way to go and that 44% in ideal conditions may not translate into 44% in non-trial conditions, the above article being one of the cautioning voices.

Presumably timed to coincide with World Aids Day on the 1st of December, this good news is likely to dominate the headlines for some time to come. I needn't go through the ins and outs of the trial, they are widely available. And there are even some good critiques that raise questions that need to be asked about an approach to a disease that depends entirely on some drugs.

Technologies such as antiretroviral treatment (ART) are great when they are used to prevent and treat a virus like HIV.But something that bothers me about HIV drugs is that the, arguably more important, objective of preventing HIV transmission by finding out what its determinants are and mitigating them has long gone out the window.

I have argued elsewhere that a significant amount of HIV transmission comes from unsafe medical practices. The WHO estimates a figure of 260,000, likely to be on the low side. No drug is required to prevent this so-called nosocomial (or iatrogenic) transmission of HIV. All that is required is good, affordable healthcare.

But there doesn't seem to be much appetite for providing people with what they really need. Single diseases have always had greater appeal and the exaggerated association of HIV transmission with sex continues to make it the biggest single recipient of health funding ever.

Sean Strub has an interesting article on post-exposure prophylaxis (PEP), antiretroviral drugs used after a suspected exposure to HIV has occurred. He has found that many people who should know about PEP don't. Although it has been widely available to healthcare workers in wealthier countries, and ostensibly in poor countries, it is not promoted widely enough among the many people who may face similar or even higher risks.

[For more information about PEP, have a look at the PEPnow site.]

I have talked to a lot of people in Kenya and Tanzania who should know about PEP but don't. This is inexcusable because PEP has been available for many years. But the fact that it is nowhere near as well known as it should be suggests to me that the current enthusiasm for PrEP is not because it could reduce and perhaps eventually eradicate the virus.

The fact that 'we' or 'science' or 'technology' can do something does not mean it will be done. 20% of deaths in under fives could be prevented by provision of clean water and sanitation, another 20% are caused by easily preventable and treatable respiratory infections. The vast majority of maternal deaths are also preventable.

Dare I suggest that developers of PrEP are more interested in the 'recreational' drug market? Something to reduce the risk of contracting HIV without the need for condoms or other precautions, perhaps?


1 comment:

Simon said...

There is a thoughtful critique of this PrEP trial by Dr Joseph Sonnabend on his blog which discusses efficacy, safety and resistance issues. He also points out that, despite all the hype this trial has attracted, the makers of the drug, Gilead, are not celebrating. Intriguing!

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