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I was really interested to read the article entitled “Stop stalling and make PrEP for HIV available now” – published on 6th June 2016.
I completely agree with Deborah Gold that pre-exposure prophylaxis is an effective, potentially game changing addition to the prevention of HIV armamentarium, to be used alongside the proper use of condoms and appropriate health education.
A fascinating newly published article by Dr Rodgers and colleagues told us that by treating HIV positive patients with highly active antiretroviral treatment and suppressing their viral loads to undetectable levels, the risk of HIV transmission is exceptionally low. In fact, in their study there were no documented cases of HIV transmission from HIV positive patients who had undetectable viral loads to their seronegative partners1. This asks the question of the importance of PrEP in the setting of serodiscordant couples, as with effective control of HIV viral loads with treatment, transmission and therefore new infections can be controlled.
Having said this, the efficacy and effectiveness of PrEP with Truvada (tenofovir and emtricitabine fixed dose combination) has been demonstrated in several studies. If this was advertised widely among high risk groups such as men who have sex with men and people from black African communities, they might be encouraged to come forward for HIV testing. If an individual was found to be HIV positive then health education, contact tracing and early treatment would not only improve the health of the individual but would also reduce the risk of further transmission, thus conferring protection at a community level.
In terms of the implementation of PrEP, there may be some issues related to the effectiveness within different populations. The concentration of tenofovir is much higher in the rectal mucosa, whereas the concentration of emtricitabine is higher in the genital tract of women compared to blood plasma concentrations2. This needs further evaluation as the protection offered by PrEP may vary depending on the gender of the user and the type of sex involved.
As the number of new HIV diagnoses is ever rising – at a rate of 17 people per day in the UK – we should implement all of the available means, such as the proper use of condoms, PrEP and the early diagnosis of HIV and initiation of treatment, in order to reduce the risk of HIV transmission in the community.
References
1 Rodger, Alison J. et al. "Sexual Activity Without Condoms And Risk Of HIV Transmission In Serodifferent Couples When The HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy". JAMA 316.2 (2016): 171.
2 Patterson, K. B. et al. “Penetration of Tenofovir and Emtricitabine in Mucosal Tissues: Implications for Prevention of HIV-1 Transmission”. Science Translational Medicine 3.112 (2011)
Ms Gold believes it is a matter of equality. She cites research suggesting that Men Who Have Sex With Men and Black Africans are at greater risk of contracting HIV.
Could Ms Gold please elaborate - what exactly is the mechanism of transmission in these two groups?
"Having sex " comes in many forms.
Thank you.
Competing interests:
Competing for NHS services. Old chap
Pre-exposure prophylaxis, condoms and treatment as prevention – a paradigm shift.
Dear Editor
I was really interested to read the article entitled “Stop stalling and make PrEP for HIV available now” – published on 6th June 2016.
I completely agree with Deborah Gold that pre-exposure prophylaxis is an effective, potentially game changing addition to the prevention of HIV armamentarium, to be used alongside the proper use of condoms and appropriate health education.
A fascinating newly published article by Dr Rodgers and colleagues told us that by treating HIV positive patients with highly active antiretroviral treatment and suppressing their viral loads to undetectable levels, the risk of HIV transmission is exceptionally low. In fact, in their study there were no documented cases of HIV transmission from HIV positive patients who had undetectable viral loads to their seronegative partners1. This asks the question of the importance of PrEP in the setting of serodiscordant couples, as with effective control of HIV viral loads with treatment, transmission and therefore new infections can be controlled.
Having said this, the efficacy and effectiveness of PrEP with Truvada (tenofovir and emtricitabine fixed dose combination) has been demonstrated in several studies. If this was advertised widely among high risk groups such as men who have sex with men and people from black African communities, they might be encouraged to come forward for HIV testing. If an individual was found to be HIV positive then health education, contact tracing and early treatment would not only improve the health of the individual but would also reduce the risk of further transmission, thus conferring protection at a community level.
In terms of the implementation of PrEP, there may be some issues related to the effectiveness within different populations. The concentration of tenofovir is much higher in the rectal mucosa, whereas the concentration of emtricitabine is higher in the genital tract of women compared to blood plasma concentrations2. This needs further evaluation as the protection offered by PrEP may vary depending on the gender of the user and the type of sex involved.
As the number of new HIV diagnoses is ever rising – at a rate of 17 people per day in the UK – we should implement all of the available means, such as the proper use of condoms, PrEP and the early diagnosis of HIV and initiation of treatment, in order to reduce the risk of HIV transmission in the community.
References
1 Rodger, Alison J. et al. "Sexual Activity Without Condoms And Risk Of HIV Transmission In Serodifferent Couples When The HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy". JAMA 316.2 (2016): 171.
2 Patterson, K. B. et al. “Penetration of Tenofovir and Emtricitabine in Mucosal Tissues: Implications for Prevention of HIV-1 Transmission”. Science Translational Medicine 3.112 (2011)
Competing interests: No competing interests