It’s time to stop accepting the status quo, PrEP Summit concludes

The biggest barrier to HIV pre-exposure prophylaxis (PrEP) becoming more available and more widely used is not cost so much as widespread acceptance of the status quo in HIV prevention, the first-ever European PrEP Summit, held in Amsterdam earlier this month, heard, Aidsmap reports.

Ignorance – among politicians, among healthcare workers, and among potential users of PrEP – was the main reason Europe lags far behind the USA in PrEP provision, despite there being a possibly more favourable climate in terms of potential drugs costs.

The decision by Dean Street clinic in London to start selling generic, off-patent Truvada – a decision given a you-heard-it-here-first announcement at the Summit by activist Greg Owen of I Want PrEP Now – is just one of a number of innovative solutions countries have had to take to meet rising demand – a demand exemplified by the fact that I Want PrEP Now is now catering for about 25,000 users a month.

And yet the Summit also heard that PrEP provision in many parts of Europe has scarcely started. In eastern Europe, despite international agencies like the World Health Organization (WHO) having given PrEP their full backing for several years, small pilot studies are only just now starting or planned to start this year.

These countries, of course, still face difficulty in providing treatment to people who already have HIV. But the fact that PrEP provision is even being contemplated in Russia, where a pilot study amongst men who have sex with men is planned to start in September, and is already underway in Ukraine and Georgia, may be a hopeful sign that PrEP-using gay men have something to contribute not only to HIV prevention but to addressing the stigma that surrounds gay men, trans people and other populations at risk of HIV.

More worrying is the fact that PrEP uptake has been lower than expected in some countries – including France, which led the way with free PrEP provision via a National Health Service in 2016. Studies and clinical experience show that there may be several reasons for this. Firstly, knowledge of PrEP is still very low among other populations, who might benefit from it, notably women, as Germany’s Harriet Langanke, citing the Flash! PrEP study, showed. Secondly, in some countries several appointments – for assessment, for HIV and other tests, and for PrEP dispensing – may be required and these ‘hoops’ may act as a disincentive to people who may be anxious about starting. Thirdly, as France’s Daniela Rojas Castro said, PrEP has added a burden in terms of staff training and hours to already stretched health systems.

The most fundamental problem may still be stigma, however. In the presentation from Ukraine, Vitaly Andres, presenting on behalf of Dzmitry Filippau of the men’s health foundation MenZDRAV, showed that gay men in Kiev are still widely ignorant about PrEP and would prefer a long-acting formulation rather than a daily pill – something African women have also expressed a preference for, and a possible indication that PrEP’s acceptability may be hindered by fears for privacy and of being seen as either gay or HIV-positive.

The PrEP in Europe Summit 2018 was attended by 120 PrEP activists, doctors and policymakers from 33 countries in Europe and central Asia, plus the US and Australia. Forty-seven were “scholars”, with travel and accommodation fully supported, while another 24 attendees were supported by PrEP in Europe’s partner organisations, AIDES, EATG, AVAC and PrEPster.

The meeting was funded primarily by the Netherlands’ HIV Funding organisation AIDSFONDS, with additional grants from AIDES and UNAIDS. In addition, funding from two pharma companies – ViiV and Merck – has supported the PrEP in Europe Initiative from the start and made such a meeting possible.