New paths of HIV prevention

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Brook Lynch
7 years ago
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1 New paths of HIV prevention Joe E. McAdams Director of HIV Training Service HIV Connection Community Partner Advocate Austin PrEP Access Project Some topics we will cover today: Pre exposure Prophylaxis (PrEP) o It works. o Success is not the result of perfection. o Like all prevention, this is not one size fits all. o Risk of resistance vs. benefit o Why PrEP in Texas? o The PrEP pipeline. o Self reported benefits for people who take PrEP. What motivates me: PrEP is harm/risk reduction Harm/risk reduction is about safely managing a wide range of risk behaviors and the harms associated with them. (Marlatt, 1998, p. xvii) Why is PrEP such a big deal?... A brief look at how this all began. 1

2 Clinical finding: It works o iprex: PrEP reduced the risk of getting HIV by 44% among all the study participants, and by more than 90% among men with detectable levels of the drug in their blood and up to 100% protected for those who reported taking PrEP everyday. o Partners PrEP: PrEP reduced the risk of getting HIV by 75% overall, and by 90% in people with detectable levels of the drug in their blood. o Bangkok Tenofovir Study: PrEP reduced risk of getting HIV by 49% overall, and by 75% in participants with detectable levels of the drug in their blood. AIDS.gov PrEP update IPERGAY (October, 2014) o On Demand Use (Intermittent) o 2 pills of Truvada 24 hours before sex and one daily dose for two days if sex occurred. 86% effective in preventing HIV PrEP & Women (Cortell et al, 2014) o Cervicovaginal tissue may need higher adherence and a longer uptake period compared to rectal tissue (21 days for vaginal mucosa vs. 7days for anal mucosa) o Still high protection. Dosing and efficacy: It works HIV Risk Reduction Partners PrEP Kenya, Uganda any tenofovir + emtricitabine (Truvada) 90% iprex/iprex OLE 2,749 participants any tenofovir + emtricitabine (Truvada) 92% 4 doses/week 96 % 7 doses/week % Adherence paradox HIV Protection for those who reported having greater risk was as high or higher compared to the clinical trial group that reported low risk o Heterosexuals (Partners Study) Reporting sex without condoms With STI With HIV+ partners with high viral loads o Men who have sex with men and/or Transgender women (iprex) Used cocaine Had syphilis Had anal sex with an HIV+ partner THOSE AT HIGH RISK WERE MORE ADHERENT Success is not the result of perfection Risk of resistance vs. benefit HIV incidence (per 100 persons/year) Risk reduction (versus off PrEP) Not on PrEP 3.9 On PrEP: 2 3 times/wk % On PrEP: 4 6 times/wk % On PrEP: 7 times/wk % *iprex OLE! o Only five cases of drug resistance emerged among the 4,747 participants in the Partners PrEP study. o The rate of acquiring a resistance mutation while on antiretroviral therapy is actually higher than the rate so far seen of acquiring a resistance mutation while on PrEP. Most HIV mutations that develop are treated with second line HIV therapy. 2

3 Why PrEP in Texas? Texans with new diagnosis by age % 19 and younger 19 and % younger 30% 5% 30s 36% 20s 24% 30s 25% 20s 40% 16 Texans living with HIV by race/ethnicity, ,073 TEXANS WERE LIVING WITH A DIAGNOSED HIV INFECTION AT THE END OF 2014 Hispanic 30% White 28% Black 37% Other/Unk 4% 17 Mode of transmission for Texans with new HIV diagnosis Challenging factors impacting adherence Hetero 27% MSM 51% 16% MSM/ 6% MSM 70% Hetero 23% 5% MSM/ 3% Younger Age Lack of social support Low perception of risk (or just low risk) Not attending appointments Partners PrEP iprex OLE! SF Demonstration Project Similar factors to lower ART adherence as well Lets consider how to engage young MSM and other populations of focus who are facing layers of stigma. 15 3

4 Benefits for the individual: What people who are taking PrEP say o Besides preventing HIV I have less shame associated with having bareback sex I communicate more with my potential sex partners I feel like I m empowered to take care of my sexual health I feel like I enjoy sex more and I m not carrying around this shroud of shame and fear One size does not fit all o PrEP is not recommended for everyone. o Condoms are still an effective tool and should be used in conjunction with PrEP and other risk reduction methods ( i.e., hierarchy of sexual risk ). Multiple forms coming o Like all prevention, PrEP will not be delivered via a singular method Pills Gels Vaginal rings/films Injectable Consider the evolution of birth control... Reducing shame = better outcomes o Patients reported increases in sexual pleasure which reduced overall reported risk for acquiring HIV. o Patients reported decreases in frequency of condomless sex during follow up in iprex and Partner s PrEP studies. The hypothesis is that PrEP allows for greater sexual satisfaction. o PrEP is risk reducing, not risk creating. PrEP pipeline PrEP is not forever or for everyone Who should take PrEP and when? o Those who are considered to be at high risk. o During periods of higher risk when other alternatives are not available. Men or women with on going or time limited risks that will give them self efficacy over prevention. Sero divergent couples?? 4

5 Summary o PrEP works and works well o PrEP is somewhat forgiving compared to other biomedical interventions o Those who adhere to PrEP stay adherent until they discontinue use Sponsored by Thank you for the work you do everyday!! 5

Condoms, PrEP, and the use of ART to prevent the sexual transmission of HIV: Overview of the science and recommendations for service providers

Condoms, PrEP, and the use of ART to prevent the sexual transmission of HIV: Overview of the science and recommendations for service providers James Wilton Coordinator, Biomedical Science of HIV Prevention