PrEP for a New Era

October 29, 2014

This was originally published on the What’sUpHIV blog that provided live coverage during HIV R4P 2014.

It was an exciting morning for pre-exposure prophylaxis (PrEP) using daily oral TDF/FTC (brand-name Truvada). In the morning plenary session, Chris Beyrer, of Johns Hopkins University and president of the International AIDS Society, spoke about HIV prevention in sex workers, gay men and other men who have sex with men. Beyrer pointed out that there is only one country implementing PrEP—the United States—at a national level.

“I can’t wait until the PrEP era begins,” Beyrer said. “Hopefully it is going to be soon.” Beyrer is a staunch human rights advocate—founder and director of the Center for Health and Human Rights at Johns Hopkins—and it is good to hear support for PrEP in the context of a rights-based response. As he noted, there are many concerns in civil society about biomedical interventions like PrEP and ART for treatment and prevention, since the medical establishment is, often, linked with the state—eg governments that may be actively criminalizing and persecuting the very populations who are being targeted with new biomedical strategies. Beyrer’s embrace of both rights and biomedical interventions is exactly what’s needed—and it will be exciting when the PrEP era, as he defines it, begins.

Speaking of the PrEP era, it took a leap forward while the plenaries were taking place, as the French research agency ANRS released a press release announcing that its IPERGAY trial, which had been designed to evaluate intermittent PrEP use, had found evidence of efficacy and was going to end its randomized, placebo-controlled design.

Briefly, this trial was launched after the iPrEx trial of daily oral PrEP showed efficacy in gay men, other men who have sex with men and transgender women. It sought to test intermittent use and had a placebo arm—a design decision that raised ethics questions from the outset, given the evidence of efficacy from iPrEx. The investigators had explained that since PrEP was not available or evaluated in France, the design was warranted. Plenary speaker Brigid Haire, who gave a compelling, nuanced talk on trial ethics and biomedical prevention, mentioned these questions specific to IPERGAY—perhaps at the precise moment that the press release was being released announcing the changes in the trial. (Kudoes to Haire and indeed anyone who isn’t checking email compulsively during conferences…)

In a delicious turn of phrase, Haire referred to the “tantalizing whiff of data” from the UK PROUD study of PrEP in gay men and other MSM. This trial found compelling evidence of efficacy earlier this month—a finding that triggered a review of the IPERGAY protocol. It’s exciting when a field evolves in real time—let’s hope it keeps happening, as fast as Beyrer suggests it should.