PrEP in Europe. Thoughts?

[rawfuckr]

I live part time in Europe and part time in USA and I'm sort of appalled about the inexistent uptake of PrEP in Europe. At this point it's abundantly clear that PrEP is extremely effective if given to the right people so it's disappointing that the EU countries are not fast tracking this intervention. I mean there doesn't seem to be even any talks of implementing programs to administer it. There is PROUD in the UK, but why wait to see the results of that when you have already a lot of data from other studies elsewhere? Do people here have any thoughts about this?

[Belfast-Bottom]

I live in the U.K. and I haven't heard of PROUD until now. I'd be grateful for any info. Are you aware of PREP being made available on the NHS in the U.K.?

[Poz1956]

. . .it's disappointing that the EU countries are not fast tracking this intervention.

It may be a situation like here where Gilead hasn't even applied to Health Canada for the approval of Truvada's use as PrEP.

Once it's approved in the UK, is it likely to be quickly adopted in other European Union countries? I know the EU breaks down some "borders" between it's members. Does that also apply for medical interventions?

[rawfuckr]

It may be a situation like here where Gilead hasn't even applied to Health Canada for the approval of Truvada's use as PrEP.

Once it's approved in the UK, is it likely to be quickly adopted in other European Union countries? I know the EU breaks down some "borders" between it's members. Does that also apply for medical interventions?

Gilead not being forthcoming could be one of the causes, but I feel it's probably more on the lines of PrEP being related to gay people and not being that important for the politics of the EU in the big scheme of things. Gay people falling through the cracks. It is also true that there just some lag with HIV medications between USA and Europe. Complera just got approved recently in Spain and not too long ago in the UK. It had been available in the USA for a while. But while for Complera things were set in motion since FDA approval I haven't heard a single thing anywhere in the EU of pushing this forward in any way or manner. Sure there are studies here and there, but that's it.

[rawfuckr]

I live in the U.K. and I haven't heard of PROUD until now. I'd be grateful for any info. Are you aware of PREP being made available on the NHS in the U.K.?

You can learn about PROUD here http://www.proud.mrc.ac.uk/ . Enrollment is now closed. There is some chance they may expand the trial to full efficacy for thousands of people but it remains to be seen as more funding is needed. If funding is obtained enrollment would resume in 2015

PrEP is not officially available anywhere in Europe, including the NHS.

Edited April 21, 2014 by rawfuckr

[bearbandit]

Europe always lags behind the USA when it comes to new drugs, unless they were developed here, and the UK never trusts other countries' test results, even though we still follow the same dosing advice (hence the disasters of AZT and high dose ritonavir, amongst others). What I hear from friends in London is not "if" but "when" I get HIV, whereas in Wales it's practically impossible to get a fuck if you're open about having HIV.

My feeling is that the UK should simply accept the American results and start a massive PrEP program. We're beginning to talk openly about TasP, when it used to be our dirty little secret. Even as recently as a year ago (I volunteer in HIV prevention) my saying that I'd had it with condoms, I was to all intents and purposes uninfectious, was greeted with shock amongst colleagues. Now, although the line is still condoms with everything, the unofficial policy is "keep your VL down as low as you can and do away with the rubbers".

If the guys who aren't poz were on PrEP we'd slow the spread of HIV immensely - I'm seeing 17 and 18 year olds getting HIV because nothing is being taught in schools. Other part of the problem is that we know there are about 26,000 with HIV who don't know they have it. (It's legal for a lab to draw off a little blood from that supplied for another test, but it has to be done anonymously, otherwise it's assault.) As Mark S King, and many others have pointed out, women have been regulating their fertility for fifty years or so by means of a daily pill, and men can't be trusted to take a pill a day?

Yes it'll put a strain on the various health service budgets, but that's easily balanced by the savings on other drugs - I take four antivirals a day and twenty odd other pills to deal with "past damage". A single truvada would be a damn sight cheaper!

[rawfuckr]

If the guys who aren't poz were on PrEP we'd slow the spread of HIV immensely - I'm seeing 17 and 18 year olds getting HIV because nothing is being taught in schools. Other part of the problem is that we know there are about 26,000 with HIV who don't know they have it.

This is so frustrating indeed. We have the tools to make HIV stop being a problem. PrEP is great but for those who can adhere which I'm not sure is everybody.

Now, TasP is where the real easy grab is. Seems clear now that poz guys who adhere to their drugs, most of them, will just not transmit the virus. If you were able to get anyone newly infected on meds right away it would make a huge difference. This of course means you need to do a lot more testing, but we have self-test devices now. These ones should be given out everywhere next to condoms with a pamphlet explaining clearly what to do if test was positive. I understand healthcare providers are obsessed about followup to a positive test, but here getting everyone knowing their status as much as possible outwheights the negatives of someone finding they are poz and freaking out. Oraquicks are so easy to use and they are cheap, which I don't understand why this is already not happening.

[bearbandit]

Part of my role (all online) is doing post-test counselling for people who've tested positive. My experience is that it takes the average "it can't happen to me" between three and eighteen months to accept the situation, and that's just the ones where we have the follow-up. I have friends who absented themselves from clinical services for several years they were so freaked out. During which time, of course, many of them had their immune system deteriorate, not seriously but enough to affect their health, and of course be infectious to others.

Even TasP isn't as reliable as one might think. Last time I had a drug holiday (now frowned on) I lost about 70 CD4 per month for seven months and added about 60,000 to my VL. I got very depressed earlier this year about the number of pills I need to take and missed a couple of four day intervals of medication (and I know I should have known better but when it's pushing 30 pills a day you get fucking tired of necking them), the result was the first detectable VL I've had since I had cryptosporidiosis in 2008.

I realise it's harder to medicate preventively (less incentive), but we need PrEP to complement TasP...

[rawfuckr]

I realise it's harder to medicate preventively (less incentive), but we need PrEP to complement TasP...

I fully support PrEP right now. My problem with it is that the protocol is too complicated for folks to follow and I can't see how it can make an impact until monthly injectables come around. I'm on it, and for me is the simplest of things. A pill a day with my other pills and that's it. I take around 10 pills a day between vitamins, cholesterol, fish oils, anti acids, and antiinflamatories for my arthritis and then Truvada PrEP. It doesn't really bother me. Takes me seconds to swallow them. But for those who don't recognize their risk and live their live on a parallel universe where STDs are an after though it's hard to see how they would all of the sudden start complying with PrEP which is not just one pill a day, but also regular doctor visits and testing. It takes commitment.

So in the bigger scheme of things it sort of feels like TasP would have more of a chance on reducing infections as a whole.

If anything the future looks bright in terms of new options for treatment and prevention, and that is great.

[Guest JizzDumpWI]

I don't believe PrEP is too hard to follow. Pretty simple to take a pill a day... But I agree, a periodic injection would be easier. We need both TasP and PrEP, and to take the stigma away from poz. While I disagree with chasing, the one good benefit is to changing the view of poz as hot and desirable.

[wood]

Europe always lags behind the USA when it comes to new drugs, unless they were developed here, and the UK never trusts other countries' test results, even though we still follow the same dosing advice (hence the disasters of AZT and high dose ritonavir, amongst others). What I hear from friends in London is not "if" but "when" I get HIV, whereas in Wales it's practically impossible to get a fuck if you're open about having HIV.

My feeling is that the UK should simply accept the American results and start a massive PrEP program. We're beginning to talk openly about TasP, when it used to be our dirty little secret. Even as recently as a year ago (I volunteer in HIV prevention) my saying that I'd had it with condoms, I was to all intents and purposes uninfectious, was greeted with shock amongst colleagues. Now, although the line is still condoms with everything, the unofficial policy is "keep your VL down as low as you can and do away with the rubbers".

Well this wasnt always the case. It wasnt until the 1960's or so that Europe got much more stringent about its drug testing regimes. Thalidomide changed EVERYTHING about drug testing. Not just in the US, but around the world. After thalidomide it wasnt enough that one country found a drug to be "safe" many different countries wanted to test it before it would be brought to market.

I agree that in certain circumstances drugs should be allowed across border without additional extensive testing. PrEP is a great example because the drug has been out for a decent amount of time in many countries and shown to be safe and effective. But I get why countries still do such extensive testing. Look at drugs like vioxx, that were later found to be dangerous. It still can happen.

http://en.wikipedia.org/wiki/Thalidomide

[rawfuckr]

Well this wasnt always the case. It wasnt until the 1960's or so that Europe got much more stringent about its drug testing regimes. Thalidomide changed EVERYTHING about drug testing. Not just in the US, but around the world. After thalidomide it wasnt enough that one country found a drug to be "safe" many different countries wanted to test it before it would be brought to market.

I agree that in certain circumstances drugs should be allowed across border without additional extensive testing. PrEP is a great example because the drug has been out for a decent amount of time in many countries and shown to be safe and effective. But I get why countries still do such extensive testing. Look at drugs like vioxx, that were later found to be dangerous. It still can happen.

http://en.wikipedia.org/wiki/Thalidomide

Truvada PrEP has already been approved in Europe for a long time for the treatment of HIV so it's not like it's a brand new drug everywhere. Also I think these days the protocol for putting a drug out in the market are a lot more strict too. Another problem, to figure out efficacy for HIV vaccines and preventive methods one has to have really large trials because of the lower infection rates. This is expensive and laborious and a burden if lots of different countries have to do their own.

[wood]

Truvada PrEP has already been approved in Europe for a long time for the treatment of HIV so it's not like it's a brand new drug everywhere. Also I think these days the protocol for putting a drug out in the market are a lot more strict too. Another problem, to figure out efficacy for HIV vaccines and preventive methods one has to have really large trials because of the lower infection rates. This is expensive and laborious and a burden if lots of different countries have to do their own.

OH I agree, and really IIRC a doctor in europe could probably still prescribe truvada for PrEP as an "off label" but getting any type of coverage for it may be difficult. Really though I do think the medical community has a hard time with PrEP because it goes against 30 years of ingrained ideas and processes. Yes they are telling people to still use condoms, but they know many people wont.

[rawfuckr]

OH I agree, and really IIRC a doctor in europe could probably still prescribe truvada for PrEP as an "off label" but getting any type of coverage for it may be difficult. Really though I do think the medical community has a hard time with PrEP because it goes against 30 years of ingrained ideas and processes. Yes they are telling people to still use condoms, but they know many people wont.

My experience here in San Francisco has been the opposite. Doctors are eager to prescribe PrEP as needed and they have zero hangups about it. But of course I guess this place is more the exception than the norm. If you go to a GP in Utah I guess you have to be prepared for some explaining and fighting.

[Poz1956]

Back in February the CBC's national morning show "The Current" (8:30 to 10:00 AM) did a 20 minute segment on PrEP. [Click the Listen button or download the MP3] The Current is one of the CBC's flagship radio shows. (Canadian Broadcast Corporation - Something like NPR but with much greater market penetration) The page for that episode also includes a

(The acronym stands for: "Intervention Préventive de l'Exposition aux Risques avec et pour les hommes Gays" or "Action to Prevent Risk Exposure By and For Gay Men." It's a study in France and Montreal looking at what I'm going to call Disco Dosing of PrEP. (Day Before, Daily during the period you're fucking around, and the Next Two Days After Your Last Boink) Interestingly the study will not accept Neg men in a sero-different couple, unless it is an open relationship.

As part of my personal campaign to slow the spread of HIV, I had a chat with my GP during my last appointment. (General Practitioner - Family Medicine - Regular Doctor)

Did he know what PrEP was? (He understood the concept but thought PrEP was a brand name)

Would he proscribe it if someone asked. (Yes)

I also tried to talk to him about asking people if they wanted an HIV test as part of their annual physical. I didn't get very far on that one.

His response; it wasn't a standard part of an annual exam. I pointed out that the CDC now recommends it annually for everyone. He said he does for people "at risk" like serial monogamists. I noted that online hook-up sites have at least as many married Bi guys on them as Gay men. They often they outnumber the Gay men, and that they probably were not discussing bisexuality with their doctor. His response was to pull out the blood test form, and point out that there wasn't a check box for an HIV test. It would have to be written in. A lot of his clients are older people. I used the results from British Columbia (the home of TasP) where they are offering HIV tests to everyone who enters hospital, or goes to Emergency / Urgent Care facility. When people are given the option, 95% are saying Yes. They calculated that if they found one Poz person per thousand, it was cost effective. They are finding seven per thousand - people who did not think they were at risk. And yes, a good chunk of them were older and elderly people, who could not remember (or would not admit) any indecent that put them at risk. I guess we'll just have to agree to disagree on routine testing.

But I think the above is a good conversation for everyone to have with their GP. Even if you don't want PrEP for yourself, make sure your doc knows about it. At least they'd educated that it exists, and that it is effective. A conversation like that would make him/her think about it. Maybe they might even recommend it to some of their patients.

The testing question is as important, if not more important than PrEP. If we make testing NORMAL, people will quit putting it off, or slipping through the cracks. Regular testing would catch a lot of people who don't know they are Poz. It is the core of TasP. Push your doctor on that one too.

There is a local doctor who does a medical segment on one of the morning drive time shows. I think I'm going to talk to him and see if he'll do a segment on annual HIV testing. That seven per thousand BC experience makes it more general interest, not just gay specific. Who knows perhaps I can even get him to do a show on PrEP. Then at least more people would know it exists. I'm sure there are similar talk and TV segments in most major markets.