Pre-exposure prophylaxis (PrEP) has been approved only in the U.S. and a handful of other countries, but people at risk of contracting HIV elsewhere in the world have nevertheless found ways to get the only available PrEP drug, Truvada (tenofovir/FTC) or its generic equivalents. In a recent webinar sponsored by several HIV organizations, activists and researchers spoke about PrEP access in various parts of the world, challenges to approval and to actual use of the medication, and advocacy efforts underway.
Germany is waiting for the European Medicines Agency to approve Truvada before proceeding with its own PrEP policy, Nicholas Feustel, managing director of georgetown media in Hamburg, explained. Meanwhile, gay men have purchased the medication from Internet pharmacies via parcel-forwarding services in the United Kingdom to circumvent German prohibitions against importing medications. Even when PrEP is approved in Germany, the national health insurance system may not cover it if Truvada is classified as a "lifestyle drug," similar to erectile dysfunction drugs, according to Feustel.
Thailand is the only Asian country where PrEP is formally available, said Midnight Poonkasetwattana, executive director of APCOM. The drug is used informally to some extent in Vietnam, Singapore and Taiwan, where it is bought on the black market via the Internet. Challenges include the lack of information in Asian languages and affordability, especially for those at greatest risk of contracting HIV, he added.
The United Kingdom is in the midst of a political struggle for approval of PrEP by the National Health Service, according to Dr. Will Nutland, co-founder of PrEPster.info. Advocacy therefore has taken the form of legal actions, rallies and lobbying, in addition to information sharing on buying safe generic versions of the medication online. That route, however, is often not available to the most marginalized people at highest risk of contracting HIV, such as sex workers, migrants and young gay men, he cautioned.
In Latin America, PrEP has only very recently been approved in Peru, said Ricardo Baruch, M.P.H. Importing generic antiretrovirals into Mexico is illegal, but the country's proximity to the U.S. allows for informal access to the medication. The activist community in Mexico is worried that pushing for PrEP may obscure the current focus on HIV treatment and testing, according to Baruch, who also emphasized the need for more information in Spanish.
South Africa recently approved PrEP after some of the trials for this prevention tool were conducted there, said Brian Kanyemba of the Desmond Tutu HIV Foundation. Still, men who have sex with men (MSM) and perceive themselves to be at risk for HIV may acquire PrEP informally. The country targets prevention packages at specific key populations: sex workers, injection drug users, MSM and mixed-status couples, with young women added recently. PrEP services must be "client-centered and friendly," Kanyemba believes, should address issues of availability, cost and adherence support, and should be used in the context of other HIV-prevention measures.
The webinar was entitled "PrEP in the Wild", which is also the title of a global survey that includes sections for those using Truvada informally, medical providers who manage such patients and people who unsuccessfully tried to get the drug through unofficial channels, webinar host Jim Pickett said. He asked that the survey be widely circulated in order to gather sufficient data on the informal use of PrEP.