3/24/2016
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 o o o o o o
It works. Success is not the result of perfection. Like all prevention, this is not one size fits all. Risk of resistance vs. benefit Why PrEP in Texas? The PrEP pipeline. 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.
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Clinical finding: It works
PrEP update
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.
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
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.
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. 7 days for anal mucosa) o Still high protection.
AIDS.gov
Dosing and efficacy: It works HIV Risk Reduction Partners PrEP
Kenya, Uganda
any tenofovir + emtricitabine (Truvada) iPrEX/iPrEX OLE
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
90% 2,749 participants
any tenofovir + emtricitabine (Truvada)
92%
4 doses/week
96 %
7 doses/week
96 – 100%
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
THOSE AT HIGH RISK WERE MORE ADHERENT
Success is not the result of perfection
HIV incidence (per 100 persons/year)
Risk reduction (versus off‐ PrEP)
Not on PrEP
3.9
‐
On PrEP: 2 – 3 times/wk
0.56
84%
On PrEP: 4 – 6 times/wk
0.00
92%
On PrEP: 7 times/wk
0.00
100%
*iPrEX OLE!
Risk of resistance vs. benefit 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.
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Texans with new diagnosis by age
Why PrEP in Texas?
2003 40+ 37%
2014
19 and younger 3%
19 and younger 5%
40 + 30%
20s 24%
30s 36%
30s 25% 20s 40%
Shelley Lucas, State of the State HIV/STD Prevention & Care Branch Dept of State Health Services August 3, 2015
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Texans living with HIV by race/ethnicity, 2014
80,073
White 28%
TEXANS WERE LIVING WITH A DIAGNOSED HIV INFECTION AT THE END OF 2014
Hispanic 30%
Other/Unk 4%
Black 37%
Shelley Lucas, State of the State HIV/STD Prevention & Care Branch Dept of State Health Services August 3, 2015
Shelley Lucas, State of the State HIV/STD Prevention & Care Branch Dept of State Health Services August 3, 2015
Mode of transmission for Texans with new HIV diagnosis 2003
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Challenging factors impacting adherence
2014
Hetero 27% IDU 16% MSM 51%
Hetero 23% MSM 70%
MSM/ IDU 6%
IDU 5%
Younger Age Lack of social support Low perception of risk (or just low risk) Not attending appointments
Similar factors to lower ART adherence as well
Partners PrEP iPrEX OLE! SF Demonstration Project
Lets consider how to engage young MSM and other populations of focus who are facing layers of stigma.
MSM/IDU 3%
Shelley Lucas, State of the State HIV/STD Prevention & Care Branch Dept of State Health Services August 3, 2015
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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”
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...
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 ).
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??
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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
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Thank you for the work you do everyday!!
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