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How PrEPared are we to end HIV?

Living in Australia, at the start of the millennium you could be forgiven for thinking that HIV is no longer an issue. Recently our top public health experts proclaimed “the end of AIDS”, riding high on the success of the antiretroviral drugs that have been successfully used to bring the number of Australians being diagnosed with AIDS each year to almost 0. Death due to AIDS has gone from a mid-90s peak of thousands per year to virtually none in 2015. It’s arguably one of the biggest Australian public health victories of the 21st century.

Definitely a cause for celebration.

Australia has led the way in HIV prevention, mostly with our very early adoption of harm-reduction strategies to prevent transmission. We are one of the best countries in the world at providing clean needles, our antiretroviral programs have been effective and in general we have done a very good job at preventing people from dying of AIDS.

And whilst this does all sound rosy, there’s a darker side to the story. Preventing HIV from becoming AIDS is a fantastic achievement, and our low death rate is a monumental victory, but the sad fact is that when it comes to stopping new people from becoming infected with HIV (a life-long diagnosis in many cases) our progress has stalled. We have an estimated 30,000 people with HIV in Australia, with about 1,000 new infections a year. The number of people living with HIV is still going up, primarily because the life expectancy after diagnosis has shot through the roof since the 80’s when the disease was first recognized.

Almost all new transmissions come from several small, high-risk groups: men who have sex with men (MSM), injecting drug users (IDU) and sex workers (SW). These groups account for >75% of all new cases of HIV worldwide (in Australia the risk from sex workers is actually basically 0; it’s in other countries that this is a major factor). And whilst there is a very strong argument here for a number of prevention programs (for example we are still disgustingly judgmental about safe spaces for drug users), one of the biggest new developments in HIV prevention is currently completely unavailable in Australia.

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Pre-Exposure Prophylaxis (PrEP, because Post-Exposure Prophylaxis or PEP was already taken — public health acronyms are usually cringe worthy) is probably the most interesting way to stop people from getting sick that I know about. We have drugs that can reduce the amount of HIV in your blood down to undetectable levels; this essentially means that you have so little of the virus in your system that our current technology doesn’t know that it’s there.

This is pretty old hat. If you reduce the viral load to undetectable levels, you reduce the infection rate from someone who is HIV positive to almost 0%. And that’s amazing. For those living with HIV, it’s a massive comfort to relax and not worry every second about giving someone else the shitty disease you carry.

But what is truly amazing is that we’ve taken the idea of reducing someone’s viral load to nothing, and applied it to people who don’t yet have HIV. This means that people at high risk of contracting HIV can take a cocktail of the same drugs we give to people who live with the virus, and they are significantly less likely to catch the disease. If you have a look at that study, it suggests that the infection rate could be reduced by up to 94% if we rolled out PrEP across all of these high-risk groups.

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So why isn’t PrEP used commonly in Australia?

The first reason is that it is new and unusual; giving perfectly healthy people drugs (that come with side-effects) is not something that the medical community is used to. It’s probably going to take a while for doctors to accept the idea as a commonplace intervention, particularly given that Truvada (one of the few approved PrEP drugs) was only very recently approved for use in Australia.

But the main reason is cost; PrEP is seriously expensive. The drug is taken daily, and in the US 30 pills goes for an astonishing $1500. Whilst Australia’s drug-pricing laws mean that you will pay a significantly reduced sum, it’s extremely difficult for a private individual to pay for what is often a very long-term treatment option.

Since the drug costs so much, the Australian government isn’t willing to pay for it either; giving PrEP to every person who is at risk could easily cost millions if not hundreds of millions of dollars.

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But you know what else costs a lot? Current cases of HIV, for which the best-evidenced treatment is currently covered by the government. The US CDC estimates that each HIV infection has a lifetime cost (since it’s a lifetime disease) in the hundreds of thousands of dollars. So spending thousands a year preventing HIV transmission is actually usually cost-effective.

And whilst there is a growing push to include PrEP on the Pharmaceutical Benefits Scheme and have the government subsidize the drugs, it’s not a popular issue so there is little incentive for a conservative government to hurt the budget bottom line for something that might not see benefits for 10 years. Which is a tragedy. Remember what I said before; 1000 new cases of HIV a year in Australia.

We could make that almost none.

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