Pre-Exposure Prophylaxis for HIV prevention: what we know and what we can do

Transcription

1 Pre-Exposure Prophylaxis for HIV prevention: what we know and what we can do Bertrand Lebouché MD PhD Chronic Viral Illness Service, Division of Infectious Diseases, MUHC Department of Family Medicine MUHC Medical Grand Round March 3, 2015

2 Disclosures Supported by a Chercheur Boursier award from the Fonds de Recherche du Québec - Santé (FRQ-S) Received honoraria and acted as a consultant: Merck, ViiV, Gilead, BMS and Abbvie Research funding from: Merck

3 Plan What is PrEP? Definition Situation relative to other ARV prevention options Approved antiretrovirals The utility of PrEP HIV and MSM The origin of PrEP Animal studies Prevention of mother-to-child transmission The birth of PrEP

4 Plan Implementation of PrEP Guidelines Candidates Clinical procedure PrEP in the real world : Results presented at CROI 2015 Risk compensation The Canadian context Conclusion

5 PrEP and other ARV-based prevention options Prior to exposure Point of transmission After exposure Preventing vertical transmission (PMTCT+) Treatment of HIV+ partner PrEP Vaginal microbicides (rings) Vaginal microbicides (gels) and rectal microbicides PEP

6 Distinguishing between PrEP and PEP After exposure to HIV, infection may become established Postexposure prophylaxis (initiated soon after exposure) reduces the chance of infection Pre-exposure prophylaxis begins treatment earlier (before exposure), which might increase the prophylactic effect Pre-exposure prophylaxis HIV exposure Postexposure prophylaxis HIV infection One or very infrequent exposure Frequent exposure or high-risk activity Adapted from CCO 0 hr 36 hrs 72 hrs 1 mos 3 mos 5 mos

7 TDF/FTC (Truvada) as PrEP Only available agent for PrEP: Tenofovir Disoproxyl Fumarate (TDF) +/- emtricitabine (FTC), TDF/FTC (Truvada) Safe and well-tolerated Daily dosing of co-formulated tablet supported by PK/PD Relatively high barrier to resistance Rapid concentration in genital/rectal tissues Hendrix CW et al. PLoS One Lehman DA et l. JID Grant RM et al. AIDS, R. Landovitz, PrEP, Seattle, CROI Feb 23-26, 2015

8 The utility of PrEP : HIV and MSM

9 The need for more efficient HIV prevention particularly for MSM Canada MSM(MSM-IDU) represent 49.1% of new HIV infections annually in Canada A problem with rectal mucosa: If the transmission probability of receptive anal sex was similar to that associated with unprotected vaginal sex, 5 year cumulative HIV incidence in MSM would be reduced by 80 98% (Truvada concentrates in rectal mucosa) Beyer et al. Global epidemiology of HIV infection in MSM, The Lancet, july 2012

10 Evolution of the sexual marketplace Rapid rise of the internet (Grindr application) Increased international travel and sex tourism Globalization of community events ( circuit parties ) Prevalence of recreational (poly) drug use Emergence of a hypersexual HIV-positive identity Facilitates the expansion of social and sexual networks and the rapid acquisition of new partners High vulnerability to HIV

11 High HIV risk context for MSM in Montreal % (17,8 %) Montreal MSM: % From slide G Pialoux; Sources : OMS et Anrs/sneg

12 Condom effectiveness in gay men (CROI 2013): the studies VAX004 ( ) and EXPLORE ( ) on condom use and HIV incidence among 7725 MSM in the U.S. showed: - Consistent use in 70.5% for all anal sex with an HIV-positive partner - Heterosexual: 80% - No real difference between inconsistent use and no condom use DK Smith et al. Condom Effectiveness for HIV Prevention by Consistency of Use among MSM) in the U.S. JAIDS. December 2, R Detels et al. Seroconversion, sexual activity, and condom use among 2915 HIV seronegative men followed for up to 2 years. JAIDS 2(1):77-83, 1989.

13 Origin of PrEP : Animal models

14 What Is PrEP? Pre-exposure prophylaxis (PrEP) With PrEP, an HIV-uninfected individual takes antiretroviral medication(s) before potential HIV exposure Provision of chemopreventive agent at vulnerable site(s) prior to infection The idea of providing a medication as prophylaxis against an infectious disease is well established, for example: Use of antimalarials before traveling to malarial zones Oral contraceptives to prevent pregnancy

15 Animal models of PrEP Non human Primate Models (SIV=Monkey HIV) TDF +FTC offers better protection than TDF alone Effective protection from IV, rectal, and vaginal challenges Lower concentration in Cervico Vaginal tissues vs. rectal compartments with oral Intermittent dosing efficient (Intermittent PrEP) Garcia-Lerma JG et al. Plos Med And Science Trans med 2010 Von Rompay KK et al. JAIDS 2006 Von Rompay KK et al. JID 2002 Subbarao S et al. JID 2006 R. Landovitz, PrEP, Seattle, CROI Feb 23-26, 2015

16 Origin of PrEP : Prevention of mother-to-child transmission

17 The prevention of mother-to-child transmission of HIV Antiretrovirals (ARV) provided to HIV+ mothers and as prophylaxis to their infants is one of the key HIV prevention successes worldwide: AZT alone reduced MTCT from 25% to 8% Current ART reduces MTCT to 1% Connor et al, NEJM 1994 Shapiro et al, NEJM 2010

18 The birth of PrEP

19 iprex study: PrEP works for MSM iprex: Daily oral FTC/TDF PrEP 2499 MSM, randomized 1:1 daily oral FTC/TDF vs placebo 11 sites (Brazil, Ecuador, Peru, South Africa, Thailand, US) 70% from Andean sites Young high risk MSM: 50% <25 yrs Median 18 partners in 12 wks prior to enrollment

20 iprex: HIV protection 100 infections after randomization 36 on FTC/TDF 64 on placebo Efficacy estimate (mitt): 44% reduction in HIV acquisition (95% CI 15%-63%) Weeks on Study

21 Mild side effects. All creatinin elevations resolved after stopping Truvada Headache, nausea, and unintentional weight loss of 5% in the first few weeks of pill use. Affected less than 1 in 20 participants.

22 iprex: Protection and adherence Overall >90% Adherence Detectable Drug Levels Grant R. et al. NEJM 2010; 363:

23 Seroconverterr (patient) iprex: HIV risk is not constant among HIV seroconverters condomless RAI no condomless RAI RAI: Receptive Anal Intercourse Randomised Phase Study Week Grant R et al, CROI 2013, Atlanta.

24 In 2012, the U.S. FDA approved Truvada, a once-daily pill, for use as PrEP.

25 Dose-response relationship between adherence and efficacy of PrEP Study Population Results Overall adherence % sample with TDF in blood iprex 2499 MSM 44% efficacy FTC/TDF 51% 44% TDF2 Study 1200 Young men and women 62% efficacy FTC/TDF 79% 62% Partners PrEP Study FEM-PrEP (4758) Heterosexual couples 2021 Women 75% efficacy FTC/TDF 6% efficacy FTC/TDF 82% 75% 15% VOICE 3021 Women No efficacy TDF FTC/TDF ongoing 30% Bangkok TDF Study 2400 IDUs 48.9% efficacy (TDF) Adapted from D. Bansberg, Adherence: The Achilles Heel of Clinical Trials, Donnell et al CROI 2012 Grant et al N Engl J Med 2010 Van Damme et al CROI 2012 Paxton et al FDA 2012

26 PrEP effectiveness Discrepancies between results largely explained by adherence (drug detectable by plasma) TDF concentrates x more in rectal tissue than in cervico-vaginal tissues Patterson KB et al. Sci Transl Med 2011

27 Efficacy rates of prevention trials Study HPTN 052 (ARV treatment as prevention) 1 iprex (FTC/TDF) in MSM 1 Subjects with detectable drug levels 2 Reduction in HIV Transmission 96% 44% 94% Partners PrEP (FTC/TDF) in discordant couples 1 Subjects with detectable drug levels 3 Condoms in heterosexuals 4 TDF2 (FTC/TDF) in men & women 1 Medical male circumcision 1 75% 90% Condoms in US MSM 5 80% 70% 62% 54% STD treatment 1 42% CAPRISA 004 (1% TFV vaginal gel) in women 1 FEM-PrEP (FTC/TDF) in women 6, VOICE (FTC/TDF, TDF, TFV vaginal gel) in women 7, HIV vaccine (RV144) 1 1. Adapted from Abdool Karim S and QA. Lancet 2011;S : Amico R, et al. IAC Washington DC. #TUPE Baeten J, et al. NEJM 2012;367: Weller S, et al. Cochrane Database Syst Rev 2002:CD Efficacy (%) 39% Not Significant 5. Smith DK, et al. CROI 2013; Atlanta, GA. Oral #32 6. van Damme L, et al. NEJM 2012;367: Marrazzo JM, et al. CROI 2013; Atlanta, GA. Oral #26LB 27

28 HIV Incidence per 100 Person-Yrs iprex OLE: 100% adherence with daily PrEP not required to attain full benefit No infection seen in participants whose blood levels suggested 4X/week adherence HIV Incidence and Drug Concentrations < 2 Tablets/Wk 2-3 Tablets/Wk 4-6 Tablets/Wk 7 Tablets/Wk Off PrEP LLOQ Follow-up,% Risk Reduction,% 95% Cl, % to TFV-DP in fmol/punch to to 100 (combined) TFV-DP: tenofovir diphosphate (measurable tenofovir in dried blood spots) On PrEP Grant R, et al. AIDS Abstract TUAC0105LB. Graphic used with permission. Adapted from CCO. 1500

29 PrEP and HIV drug resistance Concerns in regard to HIV drug resistance (HIVDR): 1. Already HIV-infected when starting PrEP 2. Non-adherent and infected while on PrEP 3. TDF-FTC also in first-line treatment: loss of future drug options? 5 cases of HIVDR have been detected in iprex, Partners PrEP, TDF2 (total of 118 infections averted) All had unrecognized (acute) infections R. Hamers, MD PhD, Transmitted ARV drug resistance: what s next?, SATuRN-PASER workshop, Bloemfontein, November 2013

30 Preventing risk of resistances Before starting PrEP: rapid HIV antibody test + a medical history +++. PrEP initiation deferred if viral symptoms until the symptoms resolve and the HIV status confirmed negative. Recent HIV exposure + viral symptoms: 3-drug PEP regimen while waiting for test results and resolution of symptoms.

31 The implementation of PrEP

32 Questions surrounding implementation Who should receive PrEP and who should be delivering PrEP? What services should be co-packaged with PrEP? Where should PrEP be delivered? When should people/laboratory testing be done (at what interval)? How will PrEP and its services be paid for? Will the people most at risk use it and adhere to it?

33 2014 World Health Organization (WHO) PrEP: Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations (Update July 2014) PrEP should be offered as a component of a comprehensive prevention intervention including unfettered availability of condoms and lubricants, routine HIV testing, risk reduction counseling and adherence coaching. STRONG Recommendation for MSM CONDITIONAL Recommendation for Serodiscordant Couples Where additional HIV prevention choices are needed. PrEP considered either FTC/TDF or TDF for this population CONDITIONAL Recommendation for Transgender Women who have sex with men Only FTC/TDF recommended NO Recommendation for People Who Inject Drugs unless negative partner in serodiscordant relationship WHO Consolidated Guidelines on HIV prevention. Switzerland. July

34 CDC guidelines January 28, 2011: Interim Guidance: Preexposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men May 14, 2014: The First Comprehensive Clinical Practice Guidelines for PrEP: federal guidelines

35 PrEP: Candidates Substantial risk of acquiring HIV infection (past 6 months) Men who have sex with men (MSM) HIV-positive sexual partner Recent bacterial STI High number of sex partners History of inconsistent/no condom use (anal sex without a condom) Commercial sex work

36 PrEP: Candidates Substantial risk of acquiring HIV infection (past 6 months) Transgender individuals Engaging in high-risk sexual behaviors

37 PrEP: Candidates Substantial risk of acquiring HIV infection (past 6 months) Heterosexual women and men HIV-positive sexual partner Recent bacterial STI High number of sex partners History of inconsistent/no condom use Commercial sex work High-prevalence area or network

38 PrEP: Candidates Substantial risk of acquiring HIV infection Injection drug users (IDU) HIV-positive injecting partner Sharing injection equipment Recent drug treatment (but currently injecting) CDC. PrEP Guideline

39 PEP or PrEP? Case step 1: 24 year old white MSM who presents 4 hours after unprotected receptive anal sex, for the first time, with his HIV-infected partner (VL detectable). PrEP is indicated for ongoing, significant risk of HIV infection. PEP is recommended for one-time high risk exposures to HIV. VL: HIV viral load

40 PEP Non-occupational Post-exposure Prophylaxis High risk exposure As soon as possible (not after 72 hrs) 28 day course Tenofovir/emtricitabine + raltegravir

41 PEP to PrEP Case step 2: 24 year old MSM on npep, day 27/28. Struggles with consistent condom use and regularly has unprotected receptive anal intercourse with his HIV-infected partner. Due to ongoing, significant risk of HIV infection: candidate for PrEP

42 PrEP: Clinical eligibility Documented negative HIV test (HIV rapid test) No signs/symptoms of acute HIV infection Normal renal function No contraindicated medications Documented hepatitis B infection & vaccination status Additional lab tests at baseline to be considered: urinalysis to check for proteinuria, STI screening, pregnancy test in women

43 PrEP: HIV testing Are signs/symptoms of acute HIV present now or in prior 4 weeks? Option 1: retest antibody in one month and defer PrEP Option 2: HIV antibody/antigen assay Option 3: HIV-1 viral load Same process you would use if for re-starting a person on PrEP after being off for over one week

44 PrEP: Additional considerations Age: PrEP use <18 yrs (no data) Reproductive plan: PrEP during preconception and pregnancy Osteopenia/osteoporosis: mild risk of bone loss associated with TDF use

45 Providing PrEP Every visit: Assess adherence Risk reduction counseling Provide condoms After confirmation of clinical eligibility: Prescribe no more than 90-day supply of PrEP Truvada 1 tablet PO daily (tenofovir 300mg + emtricitabine 200mg) Insurance prior approval Truvada for PrEP Medication Assistance Program

46 Providing PrEP Every visit: Assess/support adherence +++ Risk reduction counseling Provide condoms 3-month visit: HIV test Assess for acute infection Check for side effects: start-up syndrome (more common in the 1 st month): TDF: nausea and flatulence. FTC: rash and headache. Pregnancy testing Prescribe 90-day supply of medication

47 Providing PrEP Every visit: Assess/support adherence +++ Risk reduction counseling Provide condoms 6-month HIV test STI test Pregnancy test Renal function 90 day prescription 9-month HIV test Pregnancy test 90 day prescription 12-month HIV test STI tests Pregnancy test Renal function 90 day prescription Assess the need to continue PrEP

48 Discontinuing PrEP Positive HIV result Acute HIV signs or symptoms Non-adherence Renal disease Changed life situation: lower HIV risk

49 PrEP in the real world PROUD study Ipergay Partner PrEP

50 PROUD: Pragmatic Open-Label Randomized Trial of PrEP Randomized, multicenter, open-label pilot in the UK Study design High-risk, HIV-uninfected MSM engaging in UAI N=500 Planned Immediate PrEP (IMM) (n=250) Delayed PrEP (DEF) (start at Month 12) (n=250) Primary endpoint: HIV seroconversion between randomization and Month 12 Secondary endpoints: Safety, adherence, sexual behavior, resistance development, incremental cost per HIV infection averted and cost per QALY Oct 2014: the PROUD Trial Steering Committee announced that participants on the deferred arm of the study, who had not yet started PrEP, would be offered the opportunity to begin PrEP ahead of schedule UAI Unprotected anal intercourse All subjects received comprehensive HIV prevention services, including condoms, risk-reduction counseling, testing and treatment for sexually transmitted infections, and HIV pre- and post-test counseling McCormack S, et al. CROI 2015; Seattle, WA. #22LB

51 PROUD: Pragmatic Open-Label Randomized Trial of Pre-Exposure Prophylaxis Results : HIV incidence Group Infections (n) Follow-up (PY) Incidence/100 person-years (90% CI) Overall ( ) Immediate ( ) Deferred ( ) 86% (90% CI 58-96%) Risk Reduction p= Despite substantial use of PEP in the deferred arm, immediate PrEP was associated with an 86% reduction in HIV risk 3 infections in the immediate arm, 22 in the deferred. 86% reduction is greater than seen in placebo-controlled HIV prevention trials. 51 McCormack S, et al. CROI 2015; Seattle, WA. #22LB NNT = 13 (90% CI 9-25)

52 Rationale for on-demand PrEP Conflicting results from PrEP trials with oral daily TDF/FTC adherence: Achilles heel of PrEP More convenient dosing regimen: ondemand Could improve adherence, safety, and cost effectiveness and male prep more attractive Supported by animal models (Garcia-Lerma et al. Science Trans Med 2010)

53 IPERGAY: On-demand PrEP Study Design ANRS IPERGAY - France High-risk, HIVuninfected MSM Condomless anal sex with >2 partners within 6 mos egfr < 60 ml/min France and Quebec Double-blind, randomized On-demand FTC/TDF treatment All participants received a package of preventative measures: counselling repeated HIV testing screening & treatment for other STIs HBV vaccination condoms and gel On-demand FTC/TDF placebo On-demand regimen : 2 FTC/TDF or 2 placebo < 24hrs prior to sexual intercourse exposure, then 1 TVD/placebo dose 24hrs after; and a final dose 24hrs later. Primary endpoint: HIV seroconversion Secondary endpoints: Sexual behavior, safety events, adherence, resistance, and PK analyses Oct. 2014, the DSMB recommended that the placebo arm be discontinued and patients be offered switching into the treatment arm. Molina J, et al. CROI 2015; Seattle, WA. #23LB

54 IPERGAY: On-demand PrEP Dosing Schedule 2 tablets (FTC/TDF or placebo) 2-24 hours before sex Sexual Event 1 tablet (FTC/TDF or placebo) 24 hours later 1 tablet (FTC/TDF or placebo) 48 hours later Monday Tuesday Wednesday Thursday Friday Saturday Sunday Molina J, et al. CROI 2015; Seattle, WA. #23LB 54

55 Probability of HIV-1 infection IPERGAY: On-demand PrEP *mitt Population Log-rank test Kaplan-Meier Estimates of Time to HIV-1 Infection* Mean follow-up of 13 months: 16 subjects infected: 14 in placebo arm (incidence: 6.6 per 100 PY). 2 in TDF/FTC arm (incidence: 0.94 per 100 PY) Placebo FTC/TDF P = % relative reduction (95% CI: 40-99, P=0.002) NNT: 18 for 1 year to prevent 1 HIV infection Suboptimal adherence: 40% sexual events Months Molina J, et al. CROI 2015; Seattle, WA. #23LB

56 Partners PrEP Demonstration Project PrEP + TasP for African HIV Serodiscordant Couples 1,013 HTX SD couples in Uganda and Kenya. PrEP is offered as a bridge for the first 6 months until ART initiation by the HIV-infected partner (residual risk of HIV transmission can persist) For couples initiating ART at enrollment, PrEP is offered through 6 months, then stopped PrEP ART Stop Couples in which the infected partner delays or declines ART, PrEP is continued until 6 months after ART initiation ART delayed PrEP ART Stop With use of PrEP as a protective bridge intervention the observed HIV incidence is a 96% reduction compared to the expected incidence rate. 56. Baeten J, et al. CROI 2015; Seattle,, WA. #24 Mujugira, A. et al. CROI 2015, Seattle, WA #989

57 Implementation of PrEP: Risk compensation

58 Risk compensation PrEP trials have not seen risk compensation But. These were trials in which participants knew they might be getting a placebo People were counseled REPEATEDLY that the pill had not been shown to work yet, so condoms MUST be used all the time What will happen now that we know it works, and there are no more placebos?

59 Risk compensation? Feb 2015: HCV transmission under PreP Kaiser Permanente San Francisco largest PrEP provider in the U.S. : 2 MSM were newly infected with HCV out of 485 people under PrEP between February 2011 and December Sexual transmission confirmed with both had new gonorrhea, syphilis, and rectal chlamydia. One man reported receptive anal sex with a partner who had a penis piercing and was a bottom during group sex. No injection drug use, no occupational exposure, and no tattoos. CDC's guidelines: currently call for HCV testing before starting PrEP, but do not mention regular monitoring thereafter: HCV monitoring for ongoing Prepers + counseling about HCV JE Volk et al. Incident Hepatitis C Virus Infections Among Users of HIV Preexposure Prophylaxis in a Clinical Practice Setting. Clinical Infectious Diseases. February 18, 2015

60 Risk compensation Doxycycline as PrEP for other STI Pilot study: 30 HIV+ MSM (Los Angeles LGBT Center HIV Clinic) History of 2 syphilis infections since their HIV diagnosis Randomized: 15 with 100mg doxycycline die as PrEP against STIs for 36 weeks Incentive for control group: an additional $50, $75 and $100 if they remained STI-free at weeks 12,14 and 36 of the study Results: Doxycycline cuts STI rate by 70% in at-risk gay men. Bolan RK et al. Doxycycline prophylaxis to reduce incident syphilis among HIV-infected MSM who continue to engage in high-risk sex: a randomized, controlled pilot study. STD 42(2):

61 Implementation of PrEP: The Canadian context

62 Implementation in Canada United States is the only country to approve Truvada for the prevention of HIV infection. Health Canada has not approved Truvada for use as PrEP (Gilead didn t ask for that) PrEP is expensive and a month-long course of Truvada costs between $700 and $1000. PrEP reimbursed by RAMQ, not in CB, Ontario,. ames Wilton, Moving PrEP into practice: an update on research and implementation, CATIE 2014.

63 Quebec: Avis intérimaire sur la prophylaxie préexposition au virus de l immunodéficience humaine 2013: The Ministry of Health and Social Services in Quebec released interim guidelines for the use of TDF/FTC for PrEP among MSM and heterosexual adults: PrEP generally not recommended but can be prescribed by a specialist with expertise in HIV treatment, for individuals at high risk for HIV. Since 01/2013, Clinique médicale l Actuel has provided PrEP: 140 patients. Ministère de la Sante et des Services sociaux (July 10, 2013) Avis intérimaire sur la prophylaxie préexposition au virus de l'immunodéficience humaine

64 F. Nietzsche, La naissance de la Tragédie, Paris : Gallimard, Traduction fr. par Geneviève Bianquis. Benedict, R. (1934). Patterns of Culture. Boston and New York: Houghton Mifflin Company. Heron, J. (1996). Co-operative Inquiry: Research into the Human Condition HIV prevention and the Dionysian/ Apollonian Socially responsible Sexual decisions are rational, take long-term consequences into consideration, and are driven mainly by fear. E.g., uses condoms, takes PrEP, Apollonian typology Dionysian Seeks pleasure in risk In the heat of the moment, decisions happen based on opportunity, attraction and loneliness. Sexual behavior may have nothing to do with fear of HIV; the heat of the moment is about Sex-drugs-and-play Condom use not really adapted to this type Already on PrEP +++

65 Beyond Poz and Neg : 6 statuses from safest to most problematic 1. HIV+ Undetectable : 99.99% 2. Neg on PrEP: 86-99% 3. Neg always safe/ test 3-6 months average: 85% 4. Poz don t know viral load 5. Don t know 6. Think negative-proudly assert the status. Most dangerous and cause high % of epidemic R. Baruccco, Beyond POZ and Neg: Five HIV statuses Plus a new One, Huffington Post, 03/27/14

66 Incidence (%) Infected and unaware CDC and Prevention National HIV Surveillance System 1 85% 81% Females (n=279,200) Males (n=869,000) 70% ~25% 65% Unaware of Infxn ~75% Aware Transmission Risk 2 41% 35% 36% 32% Accounting for: US: HIV testing every year for MSM, maybe more ~54% New Infections 26% 25% of Infxn ~46% New Infections Diagnosed Linked People Living with Retained HIV Prescribed New Sexual Infections Viral to Care In Care ART Suppression n=1,148,200 HIV-infected persons, 18% of whom are unaware of their infection. 1. Hall HI, et al. 19 th IAC. Washington, DC, Abstract FrLBX Marks et al. AIDS 2006; 20:1447

67 Future of PrEP Cabotegravir SC every 3 months Rilpivirine SC every 1 month Pill Gel with applicator Vaginal film Vaginal ring (sustained delivery) Injectable (long-acting) Ideal: long acting, safe, effective, low cost and user-friendly Maximize choice & optimize affectiveness Potential for combination ARVs to increase effectiveness Potential to combine ring or injections with contraception Combining several approaches for efficient prevention Bisrat and Gulick, Next-generation oral PREP: beyond tenofovir, Current Opinion in HIV/Aids, 2012

68 Conclusion Antiretroviral treatment has an essential role to play in HIV prevention Aim of PrEP: to come through a higher risk period without HIV complicating the rest of life. Continuous PrEP for a while or intermittent

69 Conclusion Adherence has become the cornerstone of PrEP: Drugs don t work if people don t take them When people use PrEP, one of the biggest side effects is having peace of mind (less anxious about having sex): IprEX OLE qualitative study High-risk people who use PrEP are being proactive about their sexual health

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