Now that there is evidence of the efficacy of HIV pre-exposure prophylaxis (PrEP) we need to determine the best way to deliver PrEP in the 'real world' and to gather evidence of its effectiveness from countries where it is rolled out. At a meeting organised by the World Health Organisation and attended by the UNAIDS, the US Centers for Disease Control (CDC), US government, the Bill and Melinda Gates Foundation, and the investigators of the PrEP studies, participants started developing a country-level protocol development framework for PrEP demonstration projects.
There was a strong emphasis on delivering PrEP as part of a comprehensive combination HIV prevention program. We also discussed finding ways to deliver PrEP within existing services, such as family planning, male circumcision, and sexual health services, as well as through community-based organisations in some places.
Debate also focused on what counts as success. Is it retention in HIV prevention programs in general? Will PrEP allow people to engage in prevention? What role does PrEP play? How will PrEP be used? Is there 'seasonal' use for periods of higher need based on relationship status, partner separation, time of year, age? For serodiscordant couples, PrEP may be a 'bridge' to treatment as prevention i.e. for period prior to positive partner's viral load being fully suppressed. What are the reasons for the use or decline of PrEP?
Bob Grant (Gladstone Institute of Virology and Immunology) made a strong plea for changing the way we talk about PrEP towards PrEP as an opportunity to enhance prevention rather than as a last resort. Provider attitudes will therefore be important in determining success!
The draft framework that emerged from the meeting will be circulated for comment.