Every year at this time as we approach World AIDS Day it is the perfect time to sit back and reflect on the past year and see if we have moved any further forward with how we are dealing with HIV and the changing face of the local epidemic.
In the past year there has been some real forward momentum around a range of issues and we need to continue to build this as we move into 2016 and beyond. There are issues that have been bubbling up under the surface for a few years now that are gaining traction and with the recent media attention given to Charlie Sheen and his disclosure we have seen undetectable viral load (UVL) and treatment as prevention come into the general community consciousness in a big way.
Sitting along side that is the increased visibility of pre-exposure prophylaxis (PrEP) that truly has the ability to change that way the we see and deal with the epidemic here in the developed world and hopefully in the world at large.
Before I go on though I need to state one of the really important issues in all of this…we need to never stop looking for a cure and putting the idea of a cure at the front of our thinking and desire. With all of the very important talk about UVL and PrEP that is currently happening in the sector it sometimes seems to me that the search for a cure has gone onto the back burner a bit. We need to remind everyone that at the end of the day it is still a cure that we are seeking! To truly be able to cure HIV would be the most amazing thing!
Now back to UVL, treatment as prevention (TasP) and PrEP, three of the most significant issues that we need to be discussing and educating the community about so that we are all aware of these two very important issues.
According to AIDSMap.com:
All viral load tests have a cut-off point below which they cannot reliably detect HIV. This is called the limit of detection. Tests used most commonly have a lower limit of detection of either 40 or 50 copies/ml, but there are some very sensitive tests that can measure below 20 copies/ml. If your viral load is below 50, it is usually said to be undetectable. The aim of HIV treatment is to reach an undetectable viral load.
But just because the level of HIV is too low to be measured doesn’t mean that HIV has disappeared completely from your body. It might still be present in the blood, but in amounts too low to be measured. Viral load tests only measure levels of HIV in the blood, which may be different to the viral load in other parts of your body, for example in your genital fluids, gut or lymph nodes.
Along with a range of very important ongoing studies that started with the Swiss study in 2008 and have included much larger studies, the discussion about transmission of HIV from a HIV positive person to a negative sexual partner has been a topic of much discussion and comment amongst the HIV community. It has however not necessarily been discussed amongst HIV negative people and it has been the championing of HIV positive people to educate and inform partners and the community about this that has seen it gain more traction of late.
The notion that if you have a UVL and are also aware of your STI status then it would make sense for HIV positive people to be making an informed choice with their partners to have UVL with the knowledge that UVL has the same type of efficacy as using a condom. This is a vitally important move forward in an age of condom complacency in the community (especially amongst gay men). But when we look at this we must also acknowledge that for every person with HIV that has an UVL there are still people in the community that have not been tested and are unaware of their sero status.
This is the group that concerns me the most. It just reinforces the need for all of us to take responsibility to ensure that we have regular sexual health check ups. If we can get regular testing onto the agenda for people who are sexually active then we can detect HIV and take the appropriate measures of getting people onto treatment and they will very quickly find themselves with an UVL and this can assist in reducing transmission of the virus.
In 2015 it is the HIV positive people with an undetectable viral load who are the safest in terms of transmission – an amazing step forward!
According to a senior clinical and epidemiological researcher, it is possible to recommend TasP as a standalone safe sex strategy for individuals under certain conditions; these include restriction of the approach to individuals in ongoing relationships, where the person with HIV is adherent to medication and has maintained and monitored an UVL for six months or longer.
The principal reason given for limiting the strategy to couples in regular relationships was that TasP relies on a high level of communication about technical issues such as viral load, trust that the person with HIV is adherent to medication and truthful about their viral load results. Managing this could be difficult in casual sexual encounters.
And now for PrEP – (more information can be found on the AFAO website at http://www.afao.com.au)
PrEP refers to the use of anti-HIV medications by HIV-negative people in order to reduce the risk of HIV infection.
It is important to distinguish between pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP):
- PrEP involves taking medication before an anticipated risk event
- PEP involves taking medication immediately after suspected exposure to HIV.
PEP has been available in Australia for over a decade through hospital accident and emergency departments or HIV/sexual health physicians.
For information about PEP including how to obtain it go to www.getpep.info
The anti-HIV drug Truvada has been demonstrated to be effective as PrEP in clinical trials among gay men and other men who have sex with men.
The Therapeutic Goods Administration (TGA) regulates the sale and distribution of medicines and medical devices in Australia. Truvada has TGA approval for the treatment of people with HIV but not for use as PrEP.
Although the TGA has not yet approved Truvada for use as PrEP in Australia, doctors who are authorised to prescribe Truvada (i.e. those who provide HIV care), may prescribe Truvada as PrEP “off-label”. This script can then be filled by pharmacies authorised to provide HIV drugs.
Truvada for use as PrEP is not listed under the Pharmaceutical Benefits Scheme.The cost of filling a Truvada prescription for use as PrEP from an Australian pharmacy is approximately $10,000 for a year’s supply.
Individuals can legally purchase a generic version of Truvada from overseas suppliers, including on-line pharmacies.
Truvada is the brand name for a combination of two drugs – emtricitabine and tenofovir disoproxil fumarate. Generic versions have different names.
PrEP is a very exciting notion and if we can get approval to have access to it as a community then we will be reducing further the risk of transmission of HIV, and sure this needs to be, along with UVL one of the most significant moves forward in the realm of HIV for a number of years.
PrEP has been discussed for the past few years and now with the ability to access it we need to be doing all that we can to ensure that we can protect, get access to and work with our regulators to ensure that it is readily available now.
So as we head to World AIDS Day tomorrow (December 1) there is much to discuss, ruminate over and as a community get excited about!
But please never let the search for a cure fall off the agenda! We still need one and we still need to work together to find one!
This does not mean that there are not still people being diagnosed with HIV and there are not people still dying, especially in the developing countries around the world, there are – but for the first time I feel a real sense of hope moving forward!