Three Most Recent International AIDS Society Presidents Reflect on the State of Global PrEP Access

Anton Pozniak, Linda-Gail Bekker, and Chris Beyer at HIVR4P 2018
Kenyon Farrow

Three of the most recent presidents of the International AIDS Society (IAS) sat down with journalists at the HIV Research for Prevention Conference (HIVR4P 2018) in Madrid, Spain, to discuss how far we've come in the three years since they jointly wrote an article in The Lancet calling for greater global access to pre-exposure prophylaxis (PrEP).

This was 2015, three years after the U.S. Food and Drug Administration approved Truvada (FTC/tenofovir disoproxil fumarate) as PrEP in the U.S. The authors -- Linda-Gail Bekker, M.B.Ch.B., D.T.M.H., FCP(SA), of the Desmond Tutu HIV Centre; Chris Beyrer, M.D., M.P.H., of Johns Hopkins University; and Anton Pozniak, M.D., FRCP, of Chelsea and Westminster Hospital (and the current IAS president) -- pushed for greater implementation beyond U.S. borders. In the article, titled "Pre-Exposure Prophylaxis Works -- It's Time to Deliver," they call on entities from the World Health Organization (WHO) and Gilead Sciences to health ministries around the world to bring this effective prevention tool to scale.

The 2015 article came shortly after findings were presented at that year's Conference on Retroviruses and Opportunistic Infections from the PROUD and IPERGAY clinical trials and the Partners Demonstration Project, which demonstrated how powerful a tool PrEP was in preventing HIV infections. The three authors rejoined at the HIVR4P 2018 and held an informal discussion about what's changed since then and what's remained the same.

"It was abundantly clear that the science had reached a point where I felt the IAS has now got to say PrEP works; now is the time to implement it. Let the PrEP implementation period begin. That was our concept," said Beyrer, describing the initial motivation for the 2015 Lancet article.

"The landscape is becoming more radically complex. While it is incredible time of excitement, it's become more complicated," Bekker added. "How will we transition from oral PrEP to an injectable? How will that actually look on the ground? I think it's the sober moment the next morning after the excitement of recognizing we're in a good space. We do have a lot of implementation work to do, still."

During the roundtable discussion, the three global health leaders impressed upon the audience of journalists from around the world that what remains are challenges of boosting delivery mechanisms, engaging health care systems, increasing advocacy on behalf society's most vulnerable to policymakers in their countries, and encouraging people to take a pre-emptive medicine.

"We've seen, time after time, all studies show that it works, but there is resistance from some authorities to say we need more evidence. When is it going to stop before they accept it?" Pozniak asked.

At the end of 2015, the U.S. had the highest number of people taking PrEP, an estimated 79,684 people who had filled at least one prescription, according to a report from Gilead Sciences, which manufactures Truvada. Now, over 220,000 people in the U.S. are PrEP users, according to the latest estimates by AVAC's Global PrEP Tracker. Worldwide, the total number of PrEP users has grown to more than 300,000 people with a significant increase in several African countries including Kenya, Uganda, South Africa, and Zimbabwe holding nearly 50,0000 of the total global estimates. What's commonly known as "The Global South" stands at a disadvantage in accessing these biomedical interventions.

"We haven't gotten far enough in my view," said Pozniak. "With use of generics, we have a great opportunity in parts of the world, to start rolling this out in Africa -- Kenya, Uganda, Zimbabwe."

Three years ago, the WHO also began strongly recommending PrEP, going so far as establishing a target for three million people to have access to PrEP by 2020. At this moment, the global numbers are short by about 2.7 million people.

"We now have data that PrEP really is a public health intervention tool and that it can prevent everybody's risk in that network. That really matters. Now, we have a new urgency about getting it up and getting it to scale" said Beyrer.

The WHO Global PrEP Coalition has been tasked with coordinating improved implementation and scaling up PrEP campaigns.

"It's the sense of urgency that sometimes I feel is lacking. ... This is moving incredibly slowly, and I worry that we are not learning quite as fast as we should," Bekker said. "We tackled ARVs [antiretrovirals] in a different way, and I feel like we don't have the same sense of urgency about prevention, which is a problem because I think every year that is lost is infections that could be averted."

The majority of the PrEP users in the U.S. and Europe are gay, bisexual, and other men who have sex with men. And in both places, most of the users are white. Meanwhile, in Africa, most of the PrEP users are women and young girls. Vulnerable populations, including serodiscordant couples, transgender folks, and injection drug users are included in these global numbers. Parts of Latin America have only recently begun to roll out PrEP. Brazil and Peru are among the few that have already secured Truvada registration within their national health care systems.

"This empowers people to take control of their own lives, much more powerful than not having PrEP at all and taking risks. They can prevent themselves from developing HIV. I think that's a phenomenal way forward we've gotten in terms of prevention." said Pozniak.

This conversation comes on the heels of a report released on Oct. 19 by the U.S. Centers for Disease Control and Prevention detailing PrEP uptake in the U.S. According to its Morbidity and Mortality Weekly Report (MMWR), the resources are still not reaching the disproportionately affected populations. The report says, "Although black men and women accounted for approximately 40% of persons with PrEP indications, this study found that nearly six times as many white men and women were prescribed PrEP as were black men and women."

"We're trying to stop an epidemic, an infectious epidemic. This is a tool that works. Do the math. You put the tool next to the infection and you stop the infection, and that's what it's really about," said Bekker.