Dr. Laura Cheever, Associate Administrator of the HIV/AIDS Bureau at the Health Resources and Services Administration, introduced the Day 3 plenary, which focused on issues related to pre-exposure prophylaxis (PrEP).Dr. Carl Dieffenbach, Director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases, gave his assessment of the current state of PrEP and its future potential for HIV prevention. He told the audience, “There is no one magic bullet for prevention. What we have is a series of preventionstrategies,” which include HIV testing and effective delivery of treatment to help people achieve viral suppression.
As another prevention strategy, PrEP holds both promises and pitfalls, Dieffenbach said. “PrEP is amazingly effective IF the PrEP user adheres to treatment.” But he cautioned the audience that PrEP will be only a “silver-plated bullet” for HIV prevention unless it is delivered within the context of a comprehensive prevention package—and actually used as directed by those at greatest risk for HIV.
To optimize PrEP use, Dieffenbach stressed the need to increase both PrEP’s acceptability to at-risk persons and the presence of adherence support. He also emphasized the need to educate healthcare providers. Quoting Dr. Anne Schuchat, director of CDC’s National Center for Immunization and Respiratory Diseases said: “The bottom line is, PrEP works, but doctors need more prep about PrEP.”
Dieffenbach noted that providers need to know what PrEP is—and is not to empower them to do effective adherence counseling, including reminding their patients of the importance of condoms for preventing both HIV and sexually transmitted infections (STIs). This is particularly important for PrEP users who are being treated for STIs. Providers have a critical role to reinforce the importance of adherence with those patients, he said, by telling them, “Yes you have a treatable STI, but you didn’t get HIV because you continued to take your PrEP. Good work—Keep it up!”
Dieffenbach also shared his insights on scientific efforts to expand prevention options. He noted that broadly neutralizing antibodies, microbicides, and long-acting injectable agents hold great promise for the future. Although current studies are not yet ready to move to Phase 3 clinical trials, Dieffenbach said he is optimistic about the future of HIV prevention, the potential for better treatments, and—ultimately—a cure. “An HIV vaccine is within our grasp,” he said, and he expressed confidence that PrEP will become easier to use as researchers develop sustained-release formulations and interventions that are effective with only 1 to 6 doses a year.
Following Dr. Dieffenbach’s presentation, Kenneth Mayer, Medical Research Director at The Fenway Institute, moderated a panel on successes and challenges with adopting and promoting PrEP for HIV prevention. The panelists were: Dr. Dawn Smith, Centers for Disease Control and Prevention; Dr. Leandro Antonio Mena, University of Mississippi Medical Center; Dr. Demetre Daskalakis, New York City Department of Health and Mental Hygiene; Maria Courogen, Washington State Department of Health; Dr. Charlene Flash, Baylor College of Medicine; and Noël Gordon, Human Rights Campaign. Dr. Dieffenbach also joined the discussion.
The panelists noted many advantages of PrEP with respect to issues of access and uptake. Smith remarked that “…it generally takes 12 to 15 years for a new treatment to become standard of care. We are only two years in and people are showing interest.” Daskalakis said his program has focused on trying to make PrEP less “exotic” by including HIV in the framework of other chronic diseases. Mena added that his clinic, which serves a large population of black men who have sex with men (MSM), has made PrEP referrals a standard of care. Courogen shared that Washington State is developing new partnerships to facilitate access to PrEP, including an innovative plan to meet with all of the state’s major insurers to discuss how PrEP, if established as the standard of care for persons at high risk, can lead to the end AIDS by 2020.
Flash said that another major benefit of PrEP is that it can be empowering for many people, including those who engage in transactional sex to survive, those who have difficulty with sexual intimacy because they fear infecting their partners, and mixed-status couples who want to conceive safely (an approach known as “PrEP-ception”).
Panelists also discussed openly the challenges around access, adherence, and the stigma that frequently accompanies the subject of PrEP. Smith said we need to look for ways to make it easy for busy primary-care providers to get the information they need to recommend and prescribe PrEP (e.g., asking the right questions on intake forms). Flash spoke to the worries some providers have about appearing to promote “risky behavior” if they prescribe PrEP.
Gordon, who said he had been taking PrEP for roughly two years, contrasted his own experiences with adherence with those who don’t have his supportive network of healthcare providers, colleagues, and family members. “In many ways, I’m the exception to the rule. I went to my gay doctor, had my prescription filled by my gay pharmacist, and told my colleagues at the gay rights organization I work for.” He said “PrEP illuminates the challenges of our healthcare system about how we serve the most marginalized…it also presents an opportunity for mobilization and engagement.”
Throughout the day, there were many sessions on the latest issues in HIV prevention, including estimating acceptability and use of PrEP, reaching specific populations, and the impact of the Affordable Care Act on public health programs. A number of sessions focused on serving youth using culturally-competent approaches both in community and in educational settings. There are too many to mention; however, at the end of the conference, the full abstract book will be available.
One of the last activities of the day was a CDC listening session, which provided a forum for everyone—CDC leadership and everyone else in the room—to jointly consider emerging and long-standing concerns and to offer insights on areas for increased communication regarding aspects of program management, ongoing accomplishments, and areas for future collaboration.
To see a full list of all the abstracts from the conference, visit www.cdc.gov/nhpc/abstracts.html.
To read more conference updates view additional daily recaps.