PrEP: an opinion

So what’s the deal? PrEP is the big brother of Post-Exposure Prophylaxis (PEP) - treatment which is given to HIV-negative people after a possible transmission of HIV (normally within 72 hours). The difference with PrEP is that it is taken in advance, thereby preventing transmission. Neat? Well, sort of.

There are number of factors to be considered with PrEP. The main one, however, is that it is not a catch all. Transmission risk remains and at a higher rate than condom use. For people who are willing to accept this, then PrEP seems like a good idea if it is available.

For anyone who is HIV-positive, most have no choice but to accept treatment at some stage, along with everything that goes with that and all the other hurdles we have become adept at jumping over in the last 15 years whilst treatment has been available. For some, however, this will be too big a burden for them to carry in perpetuity when they aren't actually infected. How many will get tired of everything that goes with treatment and wish to stop and then go back to square one?

In addition for PrEP to be highly effective, co-infections (particularly with Hepatitis) need to be ruled out and undetectable viral load on behalf of the HIV-positive partner needs to be in play which further reduces the available pool of individuals PrEP can support.

So where can it be effective? Straight couples are using PrEP to advantage where they wish to conceive naturally and for anyone who wishes to conceive a child through timed and controlled conception, the early data is encouraging – no transmissions yet in the UK, but these HIV-negative partners are not taking treatment long term and it is only being used to conceive. This model gives us the "ifs" with regard to PrEP – if taken at the right time by the right people in the right situations it works.

The other big "if" is cost. As HIV numbers continue to grow (at a more rapid rate than in the 90s) and in times of an under-funded NHS which is now in perpetual flux, the HIV treatment costs backlash seems to be coming (think recent changes in London prescribing). The cost of treatment as prevention (costed as treatment) will mean that it is unlikely to become mainstream and the shift in focus is going to be continued prevention campaigns via awareness, behaviour change and the safe sex message. These are, after all, viewed as cheaper solutions to an expensive problem.

Is treatment as prevention another weapon in the arsenal? Certainly. Will it be the ultimate weapon to remove the risk to the HIV-negative gay community of continued HIV transmission? Sadly not.

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