HIV Prophylaxis Endorsed in Europe, but Faces Challenges

Marcia Frellick

October 25, 2015

BARCELONA, Spain — Preexposure prophylaxis (PreP) for HIV was endorsed for high-risk populations in new guidelines issued Thursday by the European AIDS Clinical Society, but there are significant barriers to widespread use, experts said here at the 15th European AIDS Conference.

First is that preventative use is not licensed by the European Medicines Agency, which approves medicines for different labels, said Tamás Bereczky, communications officer for the European AIDS Treatment Group in Budapest, Hungary.

"It causes us a lot of trouble because doctors increasingly prescribe PreP, but all of that is off-label use. The label only permits use for patients with HIV, and not without," Bereczky told Medscape Medical News.

As a consequence, he said, people often order generic versions online from India or China.

Financing, Access, and Education

Financing also poses several challenges, said Anastasia Pharris, PhD, an HIV expert from the European Centre for Disease Prevention and Control in Stockholm, Sweden.

Many countries in Europe have national health systems, but they are far from uniform, she explained. Some are completely national, some are a mix of government-run and health insurance–based systems, and some have a mix of private insurance and out-of-pocket expenses.

Europe also struggles with the bridge between PreP as a medicine delivered by clinicians and PreP as a prevention tool, she said. Prevention in Europe is often organized by nongovernmental organizations and national public health institutes.

"We haven't always been good about collaborating across the clinical and public health side. That needs to happen. We need to look at it as a comprehensive package," said Dr Pharris.

In the United Kingdom, Genitourinary Medicine and Sexually Transmitted Infections clinics are strong, she said, but networks are not as strong throughout Europe.

Infectious disease clinics could be another possible setting for the distribution of PreP, but they currently do not see patients who are HIV-negative, so this would involve a change, said Dr Pharris.

In addition, for PreP to be prescribed in a primary care setting, primary care physicians would have to familiarize themselves with antiretrovirals, "which is not always something they are comfortable with," she said.

As well, many people in Europe who could use PreP do not know it exists, she added. Therefore, education is key in coming years.

It buys time for behavior to change. And in that time a person doesn't have to catch HIV. Dr Sheena McCormack

Implementing PreP in drug treatment centers could help reach the population that injects drugs, which has been fueling a rise in HIV, particularly in Eastern Europe.

Sheena McCormack, MD, a clinical epidemiologist with Chelsea and Westminster Hospital in London, United Kingdom, told attendees here that it is important to get the message across that PreP is not for life, unlike antiretroviral therapy.

"It buys time for behavior to change," she said. "And in that time, a person doesn't have to catch HIV."

Providing PreP to high-risk people is easy, she said, because they are already accessing HIV and sexually transmitted infection services, even in countries where access is difficult and they have to make copayments.

Moral Objections

In some parts of Europe, PreP is stalled by moral objections, said Bereczky.

"Harm reduction is not even something you can talk about in Russia," he explained. "If you organize educational campaigns for men having sex with men, you may end up in prison because you're either labeled a foreign agent or you're labeled a person promoting homosexuality, and in Russia, that's a reason to be put in prison."

An important next step, he said, is disseminating scientifically sound, understandable information to the people who use drugs, men having sex with men, and women in situations where they likely will be exposed to HIV.

"We have to target information to make sure people know that you can live with HIV, and that you can stop HIV [transmission] by taking medication and protecting yourself," he said.

Mr Bereczky and Dr Pharris have disclosed no relevant financial relationships. Dr McCormack has received support from Gilead Sciences.

15th European AIDS Conference. Presented October 22, 2015.


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