Pre-Exposure Prophylaxis (PrEP)
Pre-exposure prophylaxis (PrEP) refers to the use of anti-HIV medications by HIV-negative people to reduce the risk of HIV infection.
In countries like Australia, where the majority of HIV infections occur among gay men and other men who have sex with men, PrEP has the potential to make a significant impact on the epidemic and is considered an
important new option in the HIV prevention toolbox.
PrEP is not PEP
- PrEP (pre-exposure prophylaxis) involves taking medication before an anticipated risk event
- PEP (post-exposure prophylaxis) involves taking medication immediately after suspected exposure to HIV.
PEP is available from hospital accident and emergency departments or HIV/sexual health physicians.
More information at www.getpep.info.
Truvada has been approved by Australia’s Therapeutic Goods Administration (TGA) both for the treatment of people with HIV and for use as PrEP; however the drug has not yet been added to the Pharmaceutical Benefits Scheme (PBS – the schedule of medicines that are subsidised by the government so that consumers pay no more than $37.70 per script).
TGA approval means that any doctor can prescribe Truvada for PrEP, but until the drug is subsidised for this use through a PBS listing, individuals wanting to use PrEP must continue to access it through clinical trials or personal import of generic versions of the drug. It is possible for individuals to buy Truvada in Australia but it is expensive (approximately $10,000 for a year’s supply).
AFAO and other HIV organisations are advocating for the PBS listing to occur as soon as possible.
Until Truvada is added to the PBS, individuals who cannot access the drug via trials can continue to import generic versions of Truvada from overseas suppliers, including online pharmacies.
The PrEP Access Options paper includes a step-by-step guide to buying PrEP online.
A years’ supply will cost approximately A$1,300, compared to $10,000 for Truvada purchased in Australia.
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It is wise to purchase from a reputable supplier to minimise the risk of buying damaged or out-of-date medication.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 are a number of trials in Australia investigating the acceptability, feasibility and impact of providing PrEP.
These trials are 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 is enrolling 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 will see PrEP offered to 2,000 men at risk of HIV in Queensland.
Victoria: PrEPX is the result of a partnership between the Victorian Government, Alfred Health, the Burnet Institute and the Victorian AIDS Council (VAC).
South Australia: PrEPX SA is funded by the South Australian Government. The study will offer 500 places to people at high risk of HIV infection and is anticipated that PrEPX-SA will start enrolment in April 2017.
Tasmania: PrEPX Tasmania is funded by the Tasmanian Government and is planned to open 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 will offer 2000 places and is anticipated to start enrolment in second half of 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.
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.
- Transgender women and pre-exposure prophylaxis for HIV prevention: What We Know and What We Still Need to Know (PDF – National Center for Innovation in HIV Care)
- PASH.tm Position Statement on PrEP for trans men who have sex with men (PDF)