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. Read more via AIDSmap

Barriers to PrEP still remain to be overcome

Other speakers at the PrEP symposium spoke of the barriers that continued to slow access to PrEP. In the USA, the country with by far the highest PrEP uptake, the persistent inequalities of the healthcare system continue to mean that PrEP is not reaching those who need it most.

John Brooks of the Centers for Disease Control and Prevention told the conference that PrEP was still only reaching 9% of MSM whose risk of HIV would indicate it, and the racial disparity in its use remains entrenched: whereas 26% of white MSM have an indication for PrEP and 14% are taking it, 44% of black MSM have an indication, but only 1% are taking it.

Retention continues to be a huge challenge. Annual retention in different US programmes at large is 43-64%, and in one programme in Atlanta, while two-thirds of white MSM and just over half of black MSM referred for a PrEP consultation started it, by the end of a year only 10% of white men and hardly any black men were still taking it.

Conference co-chair Susan Buchbinder added that insurance problems are a factor in this, but so is “PrEP fatigue”. Buchbinder said that HIV incidence in men who have stopped PrEP – even if they feel they are no longer at risk – is worryingly high. HIV incidence in men who stopped PrEP in Los Angeles was four times higher than in those continuing to have it prescribed, and in one study in Montreal, Canada annual HIV incidence in men who had stopped PrEP was 3.9%. Read more via AIDSmap