During the past 4 or 5 years, WHO has assessed HIV prevention alongside viral hepatitis and STIs. Looking across populations, many who are vulnerable to HIV or who have HIV are also vulnerable to or have STIs. For viral hepatitis, it’s much more of a mixed picture, because the epidemiology of viral hepatitis (B and C) is very different in populations and across geographies. For example, the prevalence and incidence of hepatitis C is high among people who inject drugs and also in some men who have sex with men (MSM). Hepatitis B is much more geographically focused in some areas so we focus on areas that have high hepatitis B prevalence; also key is prevention of mother to child transmission.
Pre-exposure prophylaxis (PrEP) for some of these viruses is an exciting field. The first trial, iPrEx, was among MSM, and when the results came out in about 2011, WHO reacted quickly and developed guidelines on implementation science to push for PrEP utilization for communities other than MSM. As more information and results became available from other populations, we were able to make broader recommendations.
The oral PrEP recommendations from WHO for anyone who’s at substantial HIV risk were released in about 2015, and there’s been a rapid scale up of countries that have adopted oral PrEP guidance since then and a gradual increase in people accessing oral PrEP. For oral PrEP, we are now thinking of different ways to deliver it so that people have much more choice about where they might have services, which was accelerated through COVID; when people couldn’t go to clinics, we had to be much more flexible about delivering PrEP, including via online services with community pickup and self-testing, because people on PrEP should test for HIV every 3 months and self-testing can help decrease clinical contact. In July, WHO released Differentiated and Simplified Prep Delivery, which includes examples of how to make PrEP more available in communities. There are also exciting projects starting to deliver PrEP through pharmacies, again with self-testing and making it a much more normalized approach to HIV prevention. We’ve also learned that PrEP is not for life and we have to be flexible about how people want to use it. People can start and stop and restart. As long as they have all the information about how to test for HIV, this can fit very much into people’s lives. For men, we recommend also offering event-driven PrEP: take two tablets before sex, one tablet right after, and one 12 hours after that.
The long-acting cabotegravir, an intermuscular injection every 8 weeks, had two big trials—HPTN 083 among MSM men and transgender women and HPTN 084 among women in Eastern Southern Africa—with stunning results with a daily or event-driven appeal. The dapivirine vaginal ring is another option for women. The ring is impregnated with dapivirine, which is released slowly over a month. It’s difficult to establish the exact efficacy of this product because the trial results weren’t as stunning as they were for cabotegravir. In an open label extension trial, efficacy was not as high as with oral PrEP or the cabotegravir injection. That said, the European Medical Agency approved the vaginal ring as an additional option, and South Africa and several other countries also now have regulatory approval. I think it’s critical to remember that we have to listen to the voices of women about what choices they want. And I think women are the right people to make these decisions by balancing what they want with the knowledge that perhaps the vaginal ring isn’t quite as efficacious.
If we’re going to get prevention products into communities, we must make them simpler. And we must broaden the number and types of people who can deliver and support use. Many countries already have nurse-led PrEP services. We want to push for nurse-led services and for support from community healthcare workers, peer supporters, and lay providers to help with the demand, answering questions about PrEP choices, and supporting people to switch, start, and stop safely. We also want to take things out of specialist clinics and make them much more available in different community sites. That’s why pharmacy-led PrEP may be an option, particularly for those who prefer more 24/7-type service.
That people who are virally suppressed on treatment don’t transmit HIV is a huge prevention option and positive message that we need communities and healthcare professionals to understand. Access is good for oral PrEP, but it’s not great. We must try to expand that access and make it easier to obtain and afford oral PrEP. But, also, we mustn’t forget condoms. They’re effective against HIV, other STIs, hepatitis, and unplanned pregnancies.
It all comes down to choice and listening to communities to understand what they want and how they want it delivered.