We Can Solve the Problems of PrEP

By Nina Hasen, Director, HIV and TB Programs, PSI

At the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa, lots of people are talking about oral PrEP, or Pre-Exposure Prophylaxis, which is the daily use of antiretrovirals to prevent HIV in those not yet infected.

But not all the talk is positive. Let’s all face it: rolling out oral PrEP has been a challenge. This is largely because governments and donors have three fears:

  1. No one will take it.
  2. Everyone will take it.
  3. It will take money away from our treatment budget.

But PrEP holds real promise, especially for those who need options beyond condoms. Let’s unpack these fears and look for a way forward.

No one will take it

From some of the earliest PrEP studies, we knew adherence would be an issue. The iPrEx trial showed a potential for 90% protection against HIV, but only if a person took the pill every day. In the study, fewer than half of participants did so. Many subsequent studies also showed low adherence, especially among women. But they also proved something critical: PrEP works if you take it. And as we’ve moved from randomized trials — where participants know they’re taking the actual medicine, as opposed to either medicine or placebo — adherence is rising. Why would this be?

Randomized clinical trials are great for proving that a medication can work. But they can be lousy for getting people to take that medication. Most of us struggle to build new habits, like taking a pill every day, and it’s even harder to build that habit when you don’t know if what you’re taking is the real thing, or just sugar. When a person knows she’s getting active medication, she’s much more motivated to take it.

Furthermore, studies recruit subjects from the populations they most want to reach, but these subjects can be motivated to participate for lots of reasons: access to better healthcare, money, or a legitimate desire to contribute to something greater than themselves. But what really motivates us to take a pill every day is the knowledge that we are at risk if we don’t. As PrEP projects move closer to real-life implementation, the women and men coming forward know they are at risk, and this translates into better pill-taking habits and more protection.

The upshot? People will take PrEP, if we do a good job helping people understand their risk.

Everyone will take it

Governments and donors also fear that if they make PrEP available, they’ll be swamped with demand, and overburdened health systems will be stretched to the breaking point.

But this is based on the assumption that the same systems that currently provide HIV services – HIV clinics – will also provide PrEP. This might be true in some cases, but certainly not all. People who don’t have HIV don’t need to go to HIV clinics and often prefer not to. And while offering PrEP requires some monitoring and clinical training, those skills fall well within the scope of most providers offering primary care. So, we don’t need to burden busy HIV doctors and nurses with the extra task of offering PrEP; we just need to train a range of providers — primary care, family planning, those in the workplace — to recognize those patients who could benefit from PrEP and offer it.

Furthermore, what we see in open-label studies, where participants know they are taking PrEP, is that the people who show up tend to be the people who would, indeed, benefit from PrEP. Programs aren’t swamped by people at low risk who are fearful. This means we don’t have to narrowly control PrEP programs, offering the drug only to people to meet our definition of “at risk.” We can make PrEP widely available, and let patients and providers make the decision together about whether or not an individual should take it.

The upshot? Making PrEP widely available and letting people choose for themselves can lead to good targeting and doesn’t have to overwhelm HIV services.

It will take money away from our treatment budget

A lot of sophisticated modeling has been done to show the relative savings of offering PrEP versus offering treatment. Depending on who gets the PrEP and where they live, the cost benefits can be substantial. However, in many countries, these savings all accrue in the future, and treatment bills must be paid today. This can make the tradeoff between ART and PrEP seem insurmountable.

But all these models make the same assumption, that the costs of PrEP will be born by the public health system, even though most people around the world prefer private health care. This is probably especially true for HIV prevention. Most people would rather pay for the confidentiality and convenience a private provider offers when talking about their sexual health. And the costs of PrEP aren’t high; generic versions of the currently approved drug cost as little as $68 per year from manufacturers; many people will only need PrEP for a few months out of the year.

The upshot? The costs of PrEP don’t have to come out of treatment budgets. Patients can carry some of these costs, and may prefer to if that means they can access PrEP privately.

PSI and PrEP

At PSI, we believe in the power of markets to improve health. We’re taking this same market-based approach to PrEP, building opportunities for people at risk for HIV to access prevention services in the private sector. At the core of our approach is the belief that if we put these consumers at the center of the program — enlisting them to help us build the intervention — then we’ll get this lifesaving prevention tool to the right people in large numbers.