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Home » EU Health, Health, HIV/ AIDS

Europe should start preparing for PrEP

Submitted by on 28 Feb 2019 – 17:13

The HIV epidemic in many European countries resembles the Australian epidemic. New infections acquired in-country are concentrated geographically and by acquisition group, with men who have sex with men (MSM) living in large conurbations most affected. Australia has achieved a higher level of testing than Europe in MSM, following successful testing campaigns and an immediate offer of treatment. Prof Sheena McCormack, Professor of Clinical Epidemiology, MRC CLinical Trials Unit at UCL, writes about why Europe should consider integrating PrEP in their existing HIV prevention package


In October, 2018 the EPIC research team from New South Wales, Australia, reported a substantial reduction in new HIV infections at population level following the rapid roll-out of pre-exposure prophylaxis (PrEP). PrEP differs from post-exposure prophylaxis – taking anti-HIV medicines after a risk of exposure to HIV – as the drugs are taken in anticipation of risk. Currently there is only one combination of anti-HIV medicines licensed for use as PrEP: tenofovir disoproxil combined with emtricitabine. However, this combination is available from several manufacturers.

The HIV epidemic in many European countries resembles the Australian epidemic. New infections acquired in-country are concentrated geographically and by acquisition group, with men who have sex with men (MSM) living in large conurbations most affected. Australia has achieved a higher level of testing than Europe in MSM, following successful testing campaigns and an immediate offer of treatment so that individuals are non-infectious within a few months. In spite of this, the rate of new infections in MSM has been constant for several years in New South Wales.

In this setting, PrEP was able to reduce the new infections at population level by 50% in the gay suburbs of Sydney and rural New South Wales. There was little impact on the non-gay suburbs of New South Wales for reasons that are not fully understood.Similar gains have been seen in the UK with the introduction of informal PrEP through self-purchase, particularly in London where testing and treatment were already at a high level and the epidemic in MSM was driven largely by individuals who had recently acquired HIV and believed themselves to be HIV negative.

As long ago as April, 2015 the European Centre for Disease Prevention and Control (ECDC) advised European Union member states to consider integrating PrEP in their existing HIV prevention package for those most at risk, starting with MSM. This followed the results of the PROUD and Ipergay studies, conducted in MSM in England and France respectively. Both observed an 86% reduction in HIV infections within the studies, and zero infections in individuals taking PrEP at the time of likely exposure.

Although these studies provided robust support for the biological effectiveness of PrEP, there was residual skepticism about the population benefit amongst public health practitioners. Nonetheless, efforts to integrate PrEP began with France leading the way in January, 2016 and implementing a national programme.

Norway followed, and then Belgium, but other countries waited until they could purchase the generic drug at considerably reduced prices, and most have yet to offer PrEP in their national HIV prevention package, so progress has been slow. The cost of the drug has been the largest obstacle and the range in prices that governments are currently paying (€50 to €428 for 30 pills) is frankly shocking. Where and how to deliver PrEP is also cited as a barrier, and there is little sense of urgency in countries where the number of new HIV infections each year is low in comparison to the burden from other diseases.

Whilst governments delay, there has been substantial informal PrEP use through self-purchase from online pharmacies to fill the gap,but this includes individuals who have had no tests and do not know their HIV status.

Now that we know there is a substantial population benefit, it is time for EU member states with epidemic patterns similar to New South Wales to shake off their apathy and embrace PrEP. Why? Because HIV requires a life-time of treatment and is an infection associated with co-morbidities including cardiovascular disease, diabetes, other infections such as TB and hepatitis, and depression. Furthermore, HIV impacts the young with high rates of acquisition observed in MSM under 25 years of age. Other groups that are affected by HIV include people who inject drugs and those in socio-sexual networks that include individuals who have migrated from countries where HIV is common.

These two groups may also benefit from PrEP, but the more pressing needs are adequate services for needle exchange and opiate substitution therapy for people who inject drugs, and more generally to increase HIV testing and the offer of immediate treatment.

With this in mind, there are a number of steps EU governments could take to accelerate efforts to control HIV, as we have the tools to achieve this in Europe. Firstly to make the necessary legislative changes to enable self-testing for HIV,nurse-prescribing, and treatment for undocumented immigrants living with HIV. Secondly to put in place a more equitable pricing for drugs and vaccines used for prevention as these are funded from public health budgets which have limited funding.

HIV has no respect for borders – getting to zero HIV infections that could be prevented in Europe is therefore a shared goal. We have the tools and it is the right thing to do – the Australians have shown us how effective a partnership between civil society, politicians and healthcare providers can be, so let us follow suit in Europe.