Pre-Exposure Prophylaxis

Kathleen Ryan, PhD, on Rapid PrEP Scale-Up and its Impact on HIV Testing Rates

A recent study conducted in Australia found that rapid scale-up of pre-exposure prophylaxis (PrEP) is a possibility without the consequence of reduced HIV testing among gay, bisexual, and other men who have sex with men (GBM) who are not taking PrEP.

Researchers arrived at their conclusion after evaluating GBM participating in PrEPX, a large PrEP implementation study in Victoria, Australia, as well as GBM not participating in PrEPX, across 5 study sites affiliated with a sentinel surveillance system (ACCESS). Segmented linear regression was used to assess trends in HIV and sexually transmitted infection (STI) testing during the pre-study and PrEPX study periods (January 2015 to June 2016, and July 2016 to March 2018, respectively).

The results of the study indicated that HIV testing rates had increased across all ACCESS sites during the pre-study period, and that HIV testing increased by 7.2 tests per month among PrEPX GBM and 8.9 tests per month among non-PrEPX GBM throughout the study period. The researchers also found that HIV testing had increased among non-PrEPX GBM in the settings of sexual health clinics and primary care clinics (18.8 and 7.9 tests per month, respectively). They noted similar trends in testing for all STIs measured in the study.

Consultant360 discussed these findings and their implications further with study author Kathleen Ryan, PhD.

CON360: In your study, you and your colleagues found that rapid PrEP scale-up was possible without a reduction in HIV testing among GBM not using PrEP. Could you elaborate on the significance of this finding, especially with respect to the impact of PrEP uptake and maintenance on existing health services?

Dr Ryan: A question that was posed to my colleagues and me quite a bit was, “how is the scale-up of PrEP going to impact people who are not on PrEP, because we don't want to disadvantage anyone who is not using PrEP?” It was really important for us to be able to show that scaling up PrEP did not negatively impact other GBM who decided not to use PrEP. In our study, we enrolled 1,000 people in 3 weeks and 2,000 in 10 weeks. We think this is really significant because it showed that our health care system can sustain a huge amount of people going onto PrEP in a very short period of time. Ultimately, our health care system was able to adapt to having all of these extra people coming in and having their 3 monthly HIV tests done, and that it did not negatively impact people who are choosing not to use PrEP. Those who were not using PrEP were still receiving the same level of health care that they could have had before the study started, which was a really important finding. This may be partly due to the health care system that we have in Australia.

CON360: How could a scale up of PrEP improve barriers to access populations that have historically been harder-to-reach?

Dr Ryan: That is an interesting question, because we did not initially anticipate that a rapid scale-up was going to make PrEP easy to access for people who have been traditionally harder to reach. In our study, we split our analysis between primary care private practices and sexual health clinics that are funded by the state government. As part of our universal health care system here, the sexual health clinics do not require patients to have a Medicare card for testing, unlike private practices. In our study, we found that many people who were receiving testing at the sexual health clinics migrated to the private general practitioner clinics because they were enrolling more study participants. This actually opened up spaces in our sexual health clinics, which can accommodate people without Medicare access. Thus, we think that there may now be increased access to HIV testing for people who do not have access to our universal health care system.

CON360: How could a scale up like that which is described in your study help reach international targets of ending the HIV epidemic by 2030, and what needs to be done to effectively reach goals like these?

Dr Ryan: In Australia, there is a huge focus on the 90:90:90, as well as the 95:95:95, which is really important. However, we have seen these targets reached in Australia for quite a few years. One of my colleagues and I recently presented work that showed that even though we had met 90:90:90 targets, we were not actually seeing declines in HIV, and that additional work was needed to see those numbers decline. Our study showed that PrEP did not have a negative impact on these numbers. We found PrEP could be scaled up really quickly without reducing testing among people who were not on PrEP, indicating that this scale-up would not negatively affect 90:90:90 gains at all. Going forward, I think scaling up PrEP and ensuring we keep expanding options with PrEP will really important.

CON360: What are some key areas of future research going forward?

Dr Ryan: Currently, my colleagues and I are still writing our paper about the impact of PrEPX Study, which ceased in April 2018 when PrEP was listed on our universal health system. In addition, Edwina Wright, MBBS, PhD, who led the PrEPX Study, has set up a free clinic for young, overseas born GBM, who have had increasing HIV diagnoses in Victoria, Australia, and many of whom do not have access to our universal health care system because they are international students. In this clinic, they are able to access PrEP clinical services for free and be educated about how to access low-cost PrEP from local pharmacies or online.

Other areas of future research include trying to increase information about and access to PrEP among populations we did not reach in our initial study, including transgender and gender-diverse populations, and how to implement models of care to engage these populations.

CON360: What key takeaways do you hope to leave with health care clinicians on this topic?

Dr Ryan: For any clinicians who counsel people on HIV risk, my takeaway is to not shy away from conversations about sexual history. In addition, though clinicians must have a specific certification to prescribe HIV treatment in Australia, any clinician can prescribe PrEP. Do not hesitate to perform risk assessment and provide PrEP to patients who are eligible and may benefit from it. Be sure to put the options on the table for patients who have an increased risk of acquiring HIV and give them the opportunity to take PrEP if it is right for them.

—Christina Vogt

Ryan KE, Asselin JE, Fairley CK, et al; PrEPXStudy Team. Trends in human immunodeficiency virus and sexually transmitted infection testing among gay, bisexual, and other men who have sex with men after rapid scale-up of preexposure prophylaxis in Victoria, Australia. Sex Transm Dis. 2020;47(8):516-524. doi:10.1097/OLQ.0000000000001187