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Review
. 2017 Dec 11:359:j5011.
doi: 10.1136/bmj.j5011.

Recent advances in pre-exposure prophylaxis for HIV

Monica Desai  1 , Nigel Field  2 , Robert Grant  3 , Sheena McCormack  4   5
Affiliations
Review

Recent advances in pre-exposure prophylaxis for HIV

Monica Desai et al. BMJ. .

Abstract

Although pre-exposure prophylaxis (PrEP)-the use of antiretroviral drugs by non-infected people to prevent the acquisition of HIV-is a promising preventive option, important public health questions remain. Daily oral emtricitabine (FTC)-tenofovir disoproxil fumarate (TDF) is highly efficacious in preventing the acquisition of HIV in people at risk as a result of a range of different types of sexual exposure. There is good evidence of efficacy in women and men, and when men who have sex with men use event based dosing. Studies have been conducted in several countries and epidemics. Because adherence to this treatment varies greatly there are questions about its public health benefit. Oral FTC-TDF is extremely safe, with minimal impact on kidney, bone, or pregnancy outcomes, and there is no evidence that its effectiveness has been reduced by risk compensation during open label and programmatic follow-up. It is too early to assess the impact of this treatment on the incidence of sexually transmitted infections (STIs) at a population level. Many challenges remain. Access to pre-exposure prophylaxis is limited and disparities exist, including those governed by race and sex. Different pricing and access models need to be explored to avoid further widening inequalities. The optimal combination prevention program needs to be defined, and this will depend on local epidemiology, service provision, and cost effectiveness. This review updates the evidence base for pre-exposure prophylaxis regarding its effectiveness, safety, and risk compensation.

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Conflict of interest statement

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: SMcC was the principal investigator and MD the trial physician in the PROUD study, which was funded in part by Gilead, which provided the drugs for free. MD, NF, and SMcC were on the writing group of the UK national pre-exposure prophylaxis guidelines. RG was the principal investigator of the iPrEx study.

Figures

Fig 1
Fig 1
Flow diagram of review
Fig 2
Fig 2
Fitted meta-regression line of the relationship between trial-level PrEP adherence and PrEP effectiveness in prevention HIV acquisition (from Fonner et al)(17)
Fig 3
Fig 3
Potential impact of expanded HIV testing, treatment and PrEP in the United States, 2015-2020
Fig 4
Fig 4
Current and ongoing HIV prevention studies (from AVAC http://www.avac.org/infographic/2016-17-percolating-pipeline)
Fig 1
Fig 1
Clinical trial evidence for HIV prevention options (http://www.avac.org/infographic/evidence-hiv-prevention-options)
See this image and copyright information in PMC

References

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