On Sunday, April 1, Australia will join only a handful of other countries in the world whose governments have made HIV pre-exposure prophylaxis (PrEP) readily available to populations at risk of HIV infection.
This step forward takes Australia much closer to achieving its pledge, made in 2014, to end new HIV transmissions by 2020.
What is prep and how does it work?
PrEP is the most powerful prevention tool currently available for people at risk of HIV infection. In people with high adherence to PrEP medication, it reduces the risk of acquiring HIV by 99%.
This compares to an HIV risk reduction of 70% for men who have sex with men (MSM) and 80% for heterosexuals who choose consistent condom use alone to prevent HIV infection. In 2015 the World Health Organisation declared that PrEP should be offered as an additional HIV prevention option to all populations at substantial risk of acquiring HIV.
In its current form, PrEP involves combining two antiretroviral drugs, tenofovir and emtricitabine, into a single tablet. PrEP is usually taken daily, but may be used just as effectively by MSM in an "on demand" fashion, taking tablets before and after sex.
What about side effects?
PrEP is generally well tolerated; in one study approximately 17% of people experienced mild side effects. These included headache, fatigue and gastro-intestinal upset within the first few weeks of starting PrEP.
These side effects mostly resolved over a few months. Only 5% of people ceased PrEP because of adverse effects. PrEP does cause a small decline in the health of the kidneys and bones, but these changes are reversible when PrEP is ceased.
People receiving PrEP see their clinician every three months to test for HIV and other sexually transmitted infections (STIs) and to monitor their overall health.
Early PREP study results in Australia
In Australia's first PrEP study, VicPrEP, we observed a decline in condom use and a rise in sexually transmitted infections (STIs), which has been reported in other PrEP studies.
There are several reasons why STIs may rise in populations using PrEP. These include less condom use, but also simply that STIs are diagnosed more frequently because people on PrEP get tested for these every three months. More research and collaboration with the community are needed to better understand the relationship between PrEP and the incidence of STIs.
Despite PrEP only arriving on the PBS from April this year, Australia is already leading the world in its PrEP use. In Australia, 31,000 MSM are estimated to be eligible for PrEP.
Thanks to strong partnerships between community activists, peak Australian HIV organisations, doctors, researchers and state and territory health departments, approximately 16,000 MSM receive PrEP through state-funded PrEP trials. Several thousand more people are thought to be personally importing PrEP online thanks to dedicated community activists.
Early signs of success in PrEP's ability to reduce HIV infections at a population level have come from New South Wales where, remarkably, about 9,000 people have enrolled in the PrEP implementation study, EPIC.
Recently, NSW reported a 32% decline in new HIV infections and a 25% overall statewide decline in new HIV diagnoses following the rollout of EPIC in 2016.
This remarkable progress should energise and provide impetus to other jurisdictions and countries, including Asia and the Pacific and particularly Eastern Europe and Central Asia where there is a dearth of PrEP use and the incidence of HIV has risen by 60% over recent years.
Getting PrEP through the PBS
From April 1 2018, people with a Medicare card who are at risk of HIV will be able to receive a script from their general practitioner or medical specialist for a three-month supply of PrEP.
The Pharmaceutical Benefits Advisory Committee approved PrEP in December 2017, which means the Pharmaceutical Benefits Scheme will subsidise its cost. People taking PrEP will pay up to $39.50, or $6.40 per month for concession cardholders.
The Commonwealth has provided funding to peak national HIV organisations to educate healthcare providers and the community about PrEP. This education must address and prevent the risk of people seeking PrEP—that is, people seeking a key preventive health measure—from being shamed and stigmatised in any healthcare setting. Hence a transgender man should be able to request and receive a vaginal swab to test for STIs in a pathology clinic in any Australian jurisdiction with impunity.
Broader PrEP awareness needed
To date, most people enrolled in Australia's PrEP studies have been MSM. The immediate challenge is to make sure all populations at risk of HIV in Australia are appropriately engaged with, educated about and have access to PrEP.
Greater HIV prevention efforts, including PrEP, must occur urgently with Indigenous Australians. The rate of HIV transmissions among Indigenous Australians increased by 33% in 2016; the rate among non-indigenous Australians declined by 22% in the same period.
People who inject drugs, transgender people, heterosexuals and people who are ineligible for Medicare are other key populations who will benefit from PrEP.
The world does not yet have a vaccine for HIV, but Australia now has the other two pillars of biomedical prevention that are necessary to end HIV: HIV treatment, which renders an HIV-positive person's risk of transmitting HIV to "effectively zero", and PrEP.
Let's work towards a "Vale HIV" for 2020.
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