Despite the undeniable battles won by actors in the fight against HIV and AIDS in recent decades – in terms of prevention, screening and access to treatment – the epidemic is still far from being eradicated.
In 2016, France authorized the marketing of a new means of prevention: PrEP. What is it about ? How does this treatment work? Who is he talking to ? The world make the point.
What is PrEP?
Pre-exposure prophylaxis, abbreviated PrEP (from the English pre-exposure prophylaxis), is an “anti-AIDS” preventive pill intended for HIV-negative people who are highly exposed to HIV (human immunodeficiency virus).
All the studies conducted in France and abroad to assess the effectiveness of this prevention tool show that there have been no cases of transmission among people who followed the treatment correctly, underlines Sida Info Service.
PrEP should be distinguished from post-exposure treatment, given urgently to an HIV-negative person after taking a high risk in order to avoid transmission of the virus. Issued by hospital emergency services, it must be started no later than forty-eight hours after taking the risk and lasts one month.
How it works ? What does the treatment consist of ?
PrEP is a tablet that combines two antiretrovirals: emtricitabine and tenofovir disoproxil. Initially, this drug was marketed under the Truvada brand. There are now generic versions, produced by different laboratories.
In France, two treatment methods are possible, explains the Sidaction association:
- continuously, with the taking of a tablet every day at the same time (with a delay of two hours maximum in case of forgetfulness);
- “on demand”, to be taken before and after risky practice (eg “chemsex”): two tablets between twenty-four hours and two hours before the act; a third twenty-four hours after the first dose; and a fourth forty-eight hours after the first dose. For practical and physiological reasons, this scheme is not applicable to people with vaginas (this includes men and transgender women). “In the context of taking “on demand”, the concentration of active product seems insufficient at the vaginal level. For lack of in-depth studies on the subject and for simplicity, cisgender women [assignées femmes à la naissance et qui s’identifient comme telles] and trans people who have a vagina do not have access to this option”regrets Dr. Radia Djebbar, medical coordinator at Sida Info Service.
Who is PrEP for?
PrEP is intended primarily for people at high risk of HIV. These are in particular men who have sex with men (MSM, whether they define themselves as gay, bisexual or heterosexual), trans people who have sex with men, people who inject drugs , sex workers, people from a high prevalence region (sub-Saharan Africa, Guyana, etc.).
These categories are not, in themselves, selection criteria. You can also not belong to these audiences and take PrEP. Moreover, as Sidaction points out, these people are not necessarily concerned throughout their sexual life, as it changes, each period not necessarily involving the use of the same means of protection.
Other prevention tools can be used, such as condoms, regular screening or post-exposure treatment.
How many people take PrEP in France?
As of June 30, 2021, the total number of people who have started PrEP treatment in France was 42,159, according to the Epi-Phare survey, a pharmacoepidemiology service created by the National Agency for the Safety of Medicines and the National Health Insurance Fund. This number does not include people who have stopped PrEP.
“The account is not there”, launched Gilles Pialoux, vice-president of the French Society for the fight against AIDS, during a press briefing. PrEP “didn’t spread enough” beyond men who have sex with other men (MSM), according to the head of the infectious and tropical diseases department at the Tenon hospital in Paris. In particular, he underlined an insufficient proportion of women or migrants among the beneficiaries of “this treatment works extremely well” and “does not oppose the condom”.
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In France, from the start of pre-exposure prophylaxis, from 2016, the main target audience was MSM. One reason for this: from the start, this community has been – and remains – hard hit by HIV.
While they represent more than a third of new contaminations, only 2.5% of people on PrEP are women. A more or less similar proportion among migrants. This very heterogeneous category includes both socially and economically integrated expatriates and undocumented refugees. It is therefore difficult to have precise figures concerning this population.
Between June 2018 and June 2019, the “initiations” (first consultations) of PrEP had jumped by 83%. They then collapsed in the spring of 2020 during the first confinement due to the Covid-19 pandemic. As a result, PrEP initiations increased by just 42% between June 2020 and June 2021. “A trend towards the resumption of an increase in initiations took shape from February 2021, and more particularly in June 2021”also observes Epi-Phare.
How to start PrEP treatment?
Initially, the first PrEP prescription had to be made by a hospital doctor who treats people living with HIV or in a hospital screening centre. Since 1er June 2021, any doctor – in particular general practitioners – can make the first prescription and renew the treatment.
During the first appointment, the doctor assesses the risk of contracting HIV and the possible contraindications to PrEP. He prescribes a kidney check-up and screening tests for sexually transmitted infections (STIs), including HIV. If all goes well, PrEP is dispensed in pharmacies (prescription only) for four weeks. After a month, the doctor repeats an HIV test and ensures that PrEP is well tolerated. The treatment is fully covered by Social Security.
A quarterly follow-up is then necessary. It makes it possible to carry out a complete screening for STIs and to control any side effects related to taking the drug. Few adverse effects have been observed: digestive disorders or headaches during the first weeks and, exceptionally, kidney problems (reversible when treatment is stopped).
What are the limitations of PrEP?
PrEP – like post-exposure treatment – protects against HIV but not against other STIs: gonorrhea, condyloma (linked to papillomaviruses), chlamydia, hepatitis, syphilis, etc. It also does not prevent unwanted pregnancies.
“PrEP must be accompanied by reinforced and individualized follow-up in sexual health: vaccinations, regular screening for STIs, treatment of STIs, pregnancy tests, contraception”insists the Aides association.
Why are some doctors reluctant? What are the associations fighting against HIV responding to?
In support of the good results of several studies, many national and international bodies recommend PrEP as a prevention tool: the World Health Organization (WHO), the National Council for AIDS and Viral Hepatitis (CNS), the Haute Autorité de santé (HAS), or the group of French experts on HIV.
However, some doctors pay lip service to it or oppose it, fearing a “general disinhibition” effect and an increase in risky behavior. Conversely, associations fighting against HIV-AIDS maintain that “preparers” precisely adopt a responsible approach: aware of the risks incurred, they choose to strengthen their prevention: they protect themselves as well as their partners. .
Florence Thune, Managing Director of the Sidaction association, insists on the importance of systematically integrating PrEP into campaigns to fight HIV-AIDS:
“This means of prevention has amply demonstrated its effectiveness. However, thehe best prevention is the one you choose. For some, it’s the condom; for others, it’s PrEP. The question is to know what we want: to be in the judgmental judgment Or is this HIV epidemic finally under control? »