PRE-EXPOSURE PROPHYLAXIS (PrEP)

Pre-Exposure Prophylaxis (PrEP)

HIV Pre-Exposure Prophylaxis (PrEP) is the regular use of HIV medications by HIV-negative people to prevent HIV acquisition.

People at high risk of HIV are eligible for PrEP. In Australia, some sexually active gay and bisexual men, transgender people and heterosexual people with an HIV positive partner who does not have an undetectable viral load are population groups that are at high risk.

Research shows that the medication used for PrEP is highly effective at preventing HIV transmission among these population groups.

On 21 March 2018, the Federal Minister for Health announced that PrEP will be subsidised by the Australian Government through the Pharmaceutical Benefits Scheme (PBS) from 1 April 2018. For more information about what this means please see the AFAO and ASHM PrEP Factsheet (English). The factsheet is also available in Plain English, Chinese, Thai, Vietnamese and Indonesian.

PrEP has the potential to significantly impact Australia’s response to the HIV epidemic. It is an important new option in the suite of HIV prevention strategies and, alongside treatment as prevention, will support Australia to meet its target of ending HIV transmission.

ESTIMATING THE NUMBER OF PrEP USERS IN AUSTRALIA

In 2015, AFAO commissioned the Kirby Institute at the University of New South Wales to provide estimates of the number of people who would need to be on PrEP in Australia to realise PrEP’s potential to reduce HIV notifications. In response, the Kirby Institute provided a report that lays out estimates of eligibility for PrEP in gay men in Australia, following the Australasian Society for HIV Medicine (ASHM) Australian Commentary on Prescribing PrEP in Australia. The Report is comprised of three documents:

The Report
The Appendum to the Report
Estimates of PrEP eligibility by jurisdiction

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PrEP can be accessed through personal importation of generic versions of Truvada from overseas suppliers, including online pharmacies. This is an option for people who aer ineligible for Medicare and unable to access PrEP through the PBS.

The PrEP Access Options paper includes a step-by-step guide to buying PrEP online.

The cost of personal importation per month is around the same as for a general patient PBS co-payment (approx. $40 a month).

Truvada is the brand name for a combination of two drugs – emtricitabine and tenofovir disoproxil fumarate. Generic versions have different names.

It is wise to purchase from a reputable supplier to minimise the risk of buying damaged or out-of-date medication.

Before importing generic Truvada for use as PrEP, you will need to obtain a prescription. While any doctor can prescribe PrEP, it is a good idea to get good medical advice from a doctor who is experienced in HIV and can discuss:

  • Potential side-effects
  • Required dosage and timing
  • Ongoing safe sex strategies
  • Regular testing for HIV and other STIs.

There were a number of trials in Australia investigating the acceptability, feasibility and impact of providing PrEP.

These trials were mainly recruiting gay and bisexual men at high risk of acquiring HIV.

NSW and ACT: EPIC NSW (Expanded PrEP Implementation in Communities in NSW) started recruiting in late February 2016. The trial enrolled people from NSW and the ACT at high risk of HIV.

Queensland: QPrEP, a joint initiative of the Department of Health, Queensland AIDS Council, and the HIV Foundation Queensland, launched August 2015. An expanded roll-out in 2016 saw PrEP offered to 2,000 men at risk of HIV in Queensland.

Victoria: PrEPX was the result of a partnership between the Victorian Government, Alfred Health, the Burnet Institute and Thorne Harbour Health (formerly the Victorian AIDS Council).

South Australia: PrEPX SA was funded by the South Australian Government. The study offered 500 places to people at high risk of HIV infection and began enrolment in April 2017.

Tasmania: PrEPX Tasmania was funded by the Tasmanian Government and opened in September 2017.

Western Australia: The WA PrEP Demonstration Project is a joint initiative of WA AIDS Council, the Department of Health and the Kirby Institute. The study offered 2000 places and began in November 2017.

The HIV antiretroviral drug Truvada has been shown to be effective as PrEP in overseas clinical trials among heterosexual men and women; however efficacy is not quite as high as it is for gay men (84% compared to 92%).

In Australia, PrEP is recommended for heterosexual men and women who may be at high risk of acquiring HIV, for example those whose partner who is HIV positive and not on treatment or has a detectable viral load.

PrEP may also be prescribed for the HIV-negative partner in couples planning to conceive naturally. In their booklet on having children, PozHet advises people to discuss this option with their doctor.

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Although research has indicated that PrEP may be effective in preventing HIV transmission among people who inject drugs, it is not a substitute for established harm reduction measures such as needle and syringe exchanges.

Peer-led drug user organisations consider that implementing PrEP for their communities is neither necessary nor cost-effective. They have also expressed concern about the potential for coercive use of PrEP in settings where the human rights of people who inject drugs are not respected.

The Australian commentary on US PrEP Guidelines recommends PrEP for people who inject drugs only in extremely limited circumstances.

Globally, transgender women are at high risk of HIV infection and while some studies have shown PrEP to be effective for this group, more research is needed. Concerns related to PrEP for transgender women include:

  • The small numbers in clinical trials of PrEP
  • Low adherence (often related to broader issues such as stigma)
  • Potential interactions between PrEP drugs and feminising hormones.

Trans men have not been included in clinical trials of PrEP; however, trans men who have sex with men are likely to be as much at risk of HIV infection as other men who have sex with men.

The Peer Advocacy Network for the Sexual Health of Trans Masculinities (PASH.tm) has called for more research and the inclusion of trans men in PrEP guidelines.

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