This article is part of POLITICO Telescope: The new AIDS epidemican ongoing exploration of the disease today.
The global battle to end the HIV epidemic is taking place on two fronts. The first is to have as many people living with the virus diagnosed as possible and quickly put them on antiretroviral treatment. This reduces the virus in their body to such a low level that it is undetectable and therefore cannot be transmitted to others. The approach is known as “undetectable = untransmittable” or “U=U*”.
The second front aims to prevent people from contracting the virus, even if they have been exposed to it – an approach known as pre-exposure prophylaxis, or PrEP. Taken as prescribed, PrEP makes a person’s body almost entirely resistant to HIV infection.
There is a critical need to provide new PrEP options that are informed and designed for communities that could benefit from PrEP in Europe..
J.ared Baeten MD, PhD, vice president of HIV clinical development at Gilead Sciences
PrEP includes antiretroviral medications that can be taken intermittently, when a person expects to be sexually active. They protect against the virus in two ways: by increasing the production of antibodies in the cells of the rectal or vaginal lining, making them less receptive to HIV, and by interfering with the ability of HIV to replicate in the body .
Almost 5 million people around the world have taken PrEP at least once, including approximately 2.8 million in Europe — and has been shown to reduce the incidence of HIV infection during sex by 99 percent. In the European Union, new HIV infections have fallen by around 45 percent since PrEP was authorized in 2016, although this decline is also partly due to U=U.
PrEP as part of combined prevention strategies
Today, PrEP mainly comes in the form of an oral tablet, which has the advantage of being inexpensive to produce and easy to store. But it is not a universal solution. Because it must be taken regularly while a person is sexually active, missing doses or running out of doses can mean becoming vulnerable to HIV again. Additionally, in the same way that some bacteria develop resistance to antibiotics, HIV that enters the bodies of people who have discontinued or discontinued their use of PrEP is more likely to become resistant to subsequent antiretroviral medications that they might then need.
PrEP taken in pill form also poses a problem for people who need to keep their PrEP use private, perhaps from family members or partners. Having to take a pill once a day, two or three times a week is something that can be difficult to hide from others. And some people, like migrants, who may not be fully integrated into a country’s health system, may struggle to access a regular supply of daily medications. Such limitations have prompted people to develop alternative and innovative ways of protecting themselves, better suited to their needs and life situations. These include longer-acting medications that can be injected.
Like existing oral medications, injectable PrEP works by stopping HIV from replicating in a person’s body, but its effect lasts much longer. In September, the EU approved the use of the first intramuscular injectable that can be administered every two months. Gilead is conducting trials until 2027 on another injectable option which, once the required effectiveness and safety has been demonstrated, could be administered subcutaneously only once every six months. This would be more practical for many people and more tailored to the circumstances of certain populations, such as migrants, and could therefore lead to better adherence and health outcomes.
HIV continues to pose a threat to public health across Europe, where in 2022 more than 100,000 people were newly diagnosed with HIV.
Jared Baeten MD, PhD, vice president of HIV clinical development at Gilead Sciences
Further afield – but still in the early stages of development and testing – are patches and implants, which would provide a continued supply of antiretroviral drugs and immunotherapies. Immunotherapies would include a broad spectrum of naturally produced or manufactured HIV antibodies, which, in theory, would prepare their bodies to resist infection.
As more types of PrEP become available, we will see greater awareness of its benefits, as more people will be able to find the version of PrEP that best suits their living conditions and personal needs . This is a fundamental principle of “combination prevention,” or innovative interventions that reflect the specific needs of the people they are trying to reach.
Prepare for the future
Despite clear scientific evidence of the benefits of PrEP, there are still some hurdles to overcome to make it a powerful tool to end HIV completely. These include investment and funding in prevention and availability, as well as anti-stigma programs.
Although the EU authorized PrEP in 2016, availability varies across the bloc. In France, the United Kingdom, Spain, Germany and, more recently, Italy, oral PrEP is available free of charge to those who would benefit from it. In Romania, although PrEP is included in the country’s new national HIV strategy, it is not yet funded and is only available through non-governmental organizations that rely on external funding sources. And in Poland, Hungary and Bulgaria, PrEP is not publicly funded and there are currently no plans to do so. In many member statesEven though PrEP is technically permitted, in practice it can be difficult to obtain, particularly for specific communities, such as women, migrants or trans people. Potential users may have difficulty, for example, accessing tests or even doctors willing to prescribe them.
Another major challenge facing health systems and providers is communicating the importance of PrEP to those who would benefit most, and thus increasing uptake. Many respondents in several studies indicated that they did not think HIV was something that affected them, or that there was a general stigma in their communities associated with sexual health issues. And some groups already facing discrimination, such as sex workers, people who inject drugs and migrants, may be reluctant to approach health systems for fear of reprisals. Again, injectable PrEP could help reach these key populations because it would provide a more discreet way to access preventative treatment.
“There is a critical need to provide new PrEP options that are informed and designed for communities that could benefit from PrEP in Europe,” says Jared Baeten MD, PhD, vice president of HIV clinical development at Gilead Sciences. “At Gilead, we are excited to engage with communities and broader stakeholders to inform our testing efforts and collaborate with them in our goal of developing person-centered innovations that can help end HIV epidemic in Europe.
Europe is leading global efforts to end HIV, but even within the bloc, PrEP use and availability varies between countries and demographics. ‘other. If the region is to become the first to completely end the HIV epidemic, the European Commission, the European Parliament and member state governments will need to lead the way in tackling stigma, promoting and prioritizing HIV prevention in all its aspects, including innovation in therapeutics strengthening financing of health systems and establishing effective pathways towards zero transmission to end HIV completely.
“HIV continues to pose a threat to public health across Europe, where in 2022 more than 100,000 people will be newly diagnosed with HIV,” says Baeten. “HIV prevention is essential and has the potential to change the trajectory of the epidemic, but stigma and other barriers limit the impact that PrEP medications can have on reducing HIV infections in Europe. We all have a responsibility to work together to make this work.
*U=U is true for two reasons: Taking anti-HIV medications as prescribed and becoming and remaining undetectable for at least six months prevents transmission of HIV to partners through sex. Undetectable means the virus cannot be measured by a viral load test (viral load <200 copies/mL)
