Many more gay men and men who have sex with men (MSM) may be using pre-exposure prophylaxis (PrEP) than figures from demonstration projects and national rollouts suggest, Michelle Rodolph, technical officer for the World Health Organization, told the HIV Research for Prevention conference (HIVR4P 2018) in Madrid in Spain on Monday.
Rodolph outlined the same statistics on known PrEP use that AVAC also presented in another session already reported: that there are known to be about 300,000 current users of PrEP, 70% of them in the USA.
However, she added, this number may be considerably exceeded by people taking PrEP informally who are buying the generic drugs from online suppliers or elsewhere. Rodolph pointed to an article from China Daily last year which suggested that, anecdotally, large numbers of gay Chinese tourists were buying PrEP in Thailand. China has not licensed tenofovir/emtricitabine for prevention but Blued.com, its largest gay dating website with 23 million users, has reported an upsurge of interest in PrEP.
A survey conducted by the Hornet dating website in Brazil found that 7% of respondents were taking PrEP and 36% were interested in it – and a similar Hornet survey of Europe reported last year found that 18% of its respondents who were taking PrEP were in Russia.
“PrEP is available online everywhere,” she emphasised, “and its use is not monitored”.
What about PrEP use by other populations vulnerable to HIV? Rodolph commented that this has been slow to take off but that after a few early schemes produced little interest and low retention among female sex workers, PrEP in now “starting to gain traction” among women in some African countries (other than Kenya, where 25,000 people are already on PrEP).
In South Africa, she commented, an initially slow roll-out is starting to gain momentum and providers are starting to see “an impact beyond PrEP” in terms of it being an incentive for female sex workers to seek out other services such as HIV and STI testing, other prevention resources such as condoms, cervical cancer screening, contraceptives and help with gender-based violence. She commented that “full PrEP” programmes needed to be designed from the start that could offer these resources, and their impact assessed.
In Zimbabwe, which has seen “increasing interest and use” among female sex workers, this may be what is beginning to happen, as PrEP has been added to a comprehensive national programme for female sex workers, Sisters with a Voice, which has already seen increases among its service users in relation to condom use with regular partners, frequent HIV testing and use of antiretroviral therapy (ART).
Programmes for other adolescent girls and young women are only just starting, however, with relatively limited uptake so far, and use of PrEP among transgender women and men is hard to gauge because too few national HIV surveillance programmes treat them as separate populations.
PrEP is still being met with resistance from conservative policy makers, she added, and national targets bear little relation to the size of the population in need. For instance, tiny Lesotho with 320,000 people with HIV has set a target of 25,000 people in the general population on PrEP, whereas huge Nigeria, with nearly 100 times the population and 3.1 million people with HIV, is only currently planning a small pilot providing PrEP to up to 700 serodiscordant couples.
“I do not think serodiscordant couples are Nigeria’s biggest population in need of PrEP,” Rodolph commented, “but they are probably the most politically acceptable one to start with.”