In the discussion about HIV-PrEP, Siegfried Schwarze sees himself "somewhere in between" - he is not in favour of it "for everyone", but considers it to be a suitable addition to the prevention toolbox in individual cases. Siegfried Schwarze is a microbiologist, HIV activist and employee at Project Information e. V.
PrEP, pre-exposure prophylaxis, is the subject of controversial debate. For some, the only thing that matters is that PrEP has prevented infections in studies. And since the end seems to justify the means, anything that prevents infections is fine. Critics of PrEP brand users as "Truvada whores", as they allegedly "abuse" HIV medication in order to indulge in their sexuality without restraint or inhibition.
I'll come out of the closet at this point: I am somewhere in between with my opinion. Although I am not in favour of PrEP for all and sundry, I think this method is certainly a suitable addition to the prevention toolbox in individual cases.
But first things first:
- Only one preparation is currently authorised for PrEP (Truvada®), and only in the USA.
- PrEP is currently a continuous therapy, which means you take the tablets every day - regardless of whether you have sex or not. Studies on episodic PrEP are still ongoing and the results will probably not be available until 2017.
- According to the latest data, PrEP only provides reliable protection against HIV infection if you take at least four tablets per week (of the seven tablets actually required). Even in studies in which highly motivated people usually take part, around a third do not manage to achieve this level of adherence. And even among those who do manage it, adherence decreases over time (and with it the risk of infection increases).
- In previous studies, PrEP provided less protection than treatment of the infected partner. One automatically wonders whether it might not make more sense to give the pills to the HIV-infected person straight away.
- PrEP is expensive (currently around 820 euros per month) and will probably not be reimbursed by health insurance companies even after it has been authorised.
- The active ingredient tenofovir may have a negative impact on kidney function and bone health if taken over a longer period of time. This may be tolerable in patients with proven HIV infection due to the benefits of the drug. However, in the case of a drug that is administered to healthy people for prevention purposes, stricter requirements must be placed on safety and harmlessness.
- It is conceivable that widespread use of the substance could lead to the development of resistance in the long term, meaning that the use of Truvada® for the treatment of HIV infection would only be effective to a limited extent. This would mean that the HIV drug, which is still the "backbone" of most treatment plans, would be "shot down" by PrEP. If there is resistance to tenofovir and emtricitabine (the components of Truvada®), treatment with first-line combinations is very difficult. Patients would then have significantly fewer treatment options.
I would like to try to summarise the essence of PrEP in one sentence:
You take HIV medication every day to prevent HIV infection, which would mean that you would have to take HIV medication every day.
Sounds a bit like a prank. What's more, swallowing pills is not enough. If PrEP is carried out properly, there are a few things to consider:
Before starting PrEP:
- Checking the general laboratory values (e.g. liver and kidney function)
- HIV test
- Hepatitis B test, vaccination if necessary (Truvada® is also effective against hepatitis B, and interrupting hepatitis B therapy can lead to a dangerous "flare-up" of the infection)
- Adherence training
- Education about other sexually transmitted infections (STIs) that are not prevented by PrEP
Regularly (every three months):
- General laboratory to ensure that PrEP has no negative effects
- HIV test
- Tests for other sexually transmitted infections (STIs)
- "Therapy compliance" training
- So you have to complete a very similar programme to someone infected with HIV.
What's more, some experts are convinced that PrEP does not prevent HIV infections at all, but only delays them. Assuming that most PrEP users are less adherent, it would be plausible that an HIV infection could still occur at some point. However, as most studies only cover a period of one to two years, the test subjects would have to be followed up for much longer to detect this effect.
But you don't have to go that far. Let's imagine a few realistic scenarios when someone says:
- "Swallowed the expensive pills for weeks, added a Viagra in the evening, went out to the bars - and then nothing happened again ... FRUST!"
- "Of course, I need the PrEP pills, but then of course I also need Viagra so that he can stand, an ecstasy so that I'm a bit more relaxed, a broad-spectrum antibiotic against STIs to be on the safe side and maybe something against fungi ... "
- "Super! PrEP has ensured that I can have sex without fear of HIV. But I've already had gonorrhoea three times and syphilis twice this year!" (Perhaps condoms would be a more suitable prevention method for this person ...)
Last but not least, it is also an ethical problem: in view of the fact that not all people worldwide (and even in developed countries) receive the HIV treatment they actually need, the administration of these drugs to people who are not infected with HIV is at least questionable. The industry, however, should be happy about this "market expansion". Why limit the target group to HIV-infected people? The number of non-infected people is so much higher!
Despite all the criticism, there are conceivable scenarios in which PrEP makes sense:
- People with an HIV-infected partner who is not receiving treatment and does not want to use condoms (a situation that is not so rare)
- People who "can't" use condoms
- Prostitutes who want to protect themselves, even if the client insists on "blank"
- Protection of children of infected untreated mothers during breastfeeding
Other scenarios are certainly conceivable, but it should also be clear that PrEP, at least in its current form, is not a prevention method suitable for the masses. Incidentally, because of the enormous financial outlay involved, it is probably not a method suitable for health insurance either ... One doctor has therefore translated the abbreviation PrEP as "problem ridden expensive prophylaxis". I think that describes it quite aptly.
