HIV Prevention in MSM: Rapid, Targeted, High-Coverage PrEP Crucial

In HIV epidemics predominantly affecting men who have sex with men (MSM), rapid and targeted high-coverage pre-exposure prophylaxis (PrEP) implementation should be prioritized as a crucial component of HIV prevention, according to a study published in the Lancet HIV.¹

Previous randomized controlled trials have demonstrated that HIV PrEP using coformulated tenofovir disoproxil fumarate and emtricitabine decrease the incidence of HIV in MSM,^2-6 and mathematical models suggest that a population-level effect of PrEP will be maximized if it is implemented quickly and with high coverage.⁷

In the EPIC-NSW prospective study (Expanded PrEP Implementation in Communities

New South Wales; ClinicalTrials.gov identifier: NCT02870790), researchers evaluated the rapid implementation of PrEP in 3700 high-risk MSM in New South Wales, Australia’s most populous state, to determine the population level effect of rapid, targeted, high-coverage PrEP implementation in MSM.¹

They found that statewide recent HIV infections in MSM declined by almost one-third 1 year after the initial recruitment target was met, and that by the end of the follow-up period, an estimated 20% of HIV-negative gay men in the study area were receiving PrEP. A decline in recent HIV infections approached 50% among gay individuals living in the suburbs of Sydney, those born in Australia, and those aged 45 years and older. The incidence in the treated cohort was less than 1 per 1000 person-years compared with the expected incidence of more than 2 per 100 person-years.

The authors concluded that, “In MSM, HIV epidemics with high levels of HIV testing and treatment, rapid PrEP implementation at scale can quickly result in substantial reductions in HIV incidence at the population level.”¹ Thus, “PrEP roll-out should be prioritised as a crucial component of HIV prevention in HIV epidemics predominantly affecting MSM.”

Disclosure: Gilead provided 2000 person-years of Truvada; the remainder of study drug was purchased from Mylan. Gilead played no role in the collection, analysis, and interpretation of data or the writing of the report or the decision to submit the paper for publication.

References

1. Grulich AE, Guy R, Amin J, et al; Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group. Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study [published online October 17, 2018]. Lancet HIV. doi: 10.1016/S2352-3018(18)30215-7
2. Grant RM, Lama JR, Anderson PL, et al; iPrEx study team. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587-2599.
3. Grant RM, Anderson PL, McMahan V, et al; iPrEx study team. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14:820-829.
4. McCormack S, Dunn DT, Desai M, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomized trial. Lancet. 2016;387:53-60.
5. Molina JM, Capitant C, Spire B, et al; ANRS IPERGAY Study Group. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373:2237-2246.
6. Molina JM, Charreau I, Spire B, et al; ANRS IPERGAY Study Group. Efficacy, safety, and effect on sexual behaviour of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: an observational cohort study. Lancet HIV. 2017;4:e402-e410.
7. Kasaie P, Pennington J, Shah MS, et al. The impact of preexposure prophylaxis among men who have sex with men: an individual-based model. J Acquir Immune Defic Syndr. 2017;75:175-183.