PrEP: HIV prevention in pill form

HIV prevention in pill form: What is Pre-Exposure Prophylaxis? 

A huge step forward is being made in HIV prevention in the form of Pre-Exposure prophylaxis (PrEP). “What is Prep?” you might ask. This medication can prevent individuals from contracting sexually transmitted HIV with up to 90% effectiveness! So why is it that PrEP isn’t a more widely known HIV prevention technique? In part, it is because PrEP is new. The FDA approved PrEP for HIV prevention in July 2012. Shockwaves of excitement are rippling through the HIV prevention community and they look like progress. But progress doesn’t mean perfection.

A pill to add to the HIV prevention methods (PrEP)

Individuals’ varying adherence to PrEP has made efficacy equivocal and thus support for implementation is hesitant. Another reason for the hesitant implementation support is that most people simply do not really understand what PrEP is. When asked if one has heard of PrEP, most people respond by saying, “wait, is that what you take after you get pricked by a needle?” Not so much. What one takes AFTER potentially being exposed to HIV is Post-exposure prophylaxis (PEP). This has been around for occupational use since the early 1990s and for non-occupational use for almost a decade. By now, most people are familiar with PEP. What one takes before exposure to HIV is Pre-exposure prophylaxis (PrEP). The familiarity with PEP and the similarity between sounds of the Pre in PrEP and the Post in PEP seems to have slowed clear information dissemination to a wider audience. It seems trivial, but the names are too similar for most people to notice the difference. The public seems to be combining not only the names but also the meanings of the prophylaxes together. I took a small poll of some informed public health and policy colleagues and they responded with the same confusion. Unfortunate for PrEP.

PrEP is a huge step forward in prevention and the word is sluggishly and ineffectively getting around. So now for the sake of clarity it is time for a birth control analogy. PrEP is similar to daily birth control to reduce the likelihood of pregnancy as a regular prevention method for those who are sexually active and do not want to conceive. PEP is like the morning after pill; a pill taken after one has had unprotected sex. Of course the similarities of the analogy end there. According to the CDC factsheet on PrEP, the prophylaxis is actually more similar to other medications taken to prevent infection from germs or viruses like anti-malarial prophylaxis taken in malaria endemic areas.

Who should use PrEP?
PrEP is an important addition to HIV prevention interventions for individuals at high risk of contracting the virus. Who is the drug best suited for? PrEP is most effective for individuals who are frequently exposed to the virus, for example someone who is HIV negative who has an HIV positive sexual partner (a sero-discordant couple) or someone in a high prevalence area who has casual unprotected sex frequently. PrEP is not a replacement for any other prevention interventions. It should be used in addition to established interventions like condoms and couples testing and treatment. PrEP has shown potential as a gender-sensitive intervention, unlike condoms. There is a potential for women who are unable to negotiate condom use with their partners to protect themselves against exposure. Like any intervention it is not for everyone and it is not without side effects or ethical implementation issues.
Ultimately having medication that can prevent sexually transmitted HIV infection in uninfected individuals is a major advancement in the field. Both program planners and potential users have been positive about welcoming PrEP as a prevention option. Although with furrowed brows, HIV/AIDS experts note that if condoms were used more effectively and …well, just more…the need for PrEP would not be so strong. There is no way of getting around the fact that there is need for a biomedical intervention backup to patch the dangerous holes that behavioral risks create and perpetuate. Additional information about how best to implement PrEP in different populations is underway. Once it is clearer how PrEP works in the real world more can be done to increase the awareness and to target the intervention to the populations that really need it.

Jasmine Buttolph, MPH