In a Lancet HIV study, Rachel Baggaley, MBBS, MSc, and colleagues noted that “scaling up access to PrEP cannot be achieved by medical doctors alone, and nurse-led PrEP delivery can help to lay the groundwork for supporting uptake of other HIV prevention approaches that will become available in the future.” In another study, this one published in BMJ, Baggaley and team concluded that “Provision of PrEP through pharmacies has been demonstrated to be feasible in the [US] and acceptable to potential end users and stakeholders in multiple settings.
Physician’s Weekly spoke with Baggaley about the WHO’s approach to PrEP, recent developments in PrEP delivery, and the studies published in BMJ and Lancet HIV.
How does WHO approach PrEP?
WHO takes HIV prevention extremely seriously and has done so for many years as part of the general response to HIV. Over the past 4 or 5 years, we’ve looked at HIV together alongside viral hepatitis and STIs and prevention.
It’s not a uniform response, but when you look across these patient populations, many who are vulnerable to HIV or who have HIV are also vulnerable to or have STIs. There are a lot of opportunities there for preventing and treating STIs.
We’ve had, for decades, prevention of HIV from mother to child, or vertical transmission, as a mainstay of the response to HIV. Now, WHO is looking at what we call triple elimination HIV, hepatitis B, and syphilis and the potential to have a much greater impact addressing these three infections together.
PrEP is a really exciting field. WHO has been working on PrEP for more than a decade. The first trial, iPrEx, was among MSM and the results came out in about 2011. WHO reacted quickly and developed guidelines on implementation to push that for communities other than MSM. As more results became available from other populations, we were able to make broader recommendations.
The oral PrEP recommendations from WHO for anyone who’s at substantial risk for HIV were released around 2015, and there’s been a rapid scale-up of countries that have adopted oral PrEP guidance since. For oral PrEP, we can now think of different ways to deliver it so that people have many more choices.
This was really accelerated by COVID-19. When people couldn’t go to clinics, we had to be flexible. There are some fantastic examples of supporting PrEP in a hybrid way with online services, community pickup, and selftesting because people on PrEP should test for HIV every 3 months, and self-testing can decrease clinical contact. WHO also released Differentiated and Simplified PrEP Delivery, which provides examples of how we can make PrEP much more available in communities.
How does your paper on delivering PrEP through pharmacies fit into this?
There are exciting projects starting to deliver PrEP through pharmacies, also with selftesting. What we’ve learned is that PrEP is not for life, and we have to be flexible about how people want to use it. People can start and stop and restart. As long as they have information about testing, this can fit very much into people’s lives. For men, we also recommend offering event-driven PrEP: two tablets before sex, one tablet right after, and one 12 hours after that.
Long acting cabotegravir, which is an intermuscular injection every 8 weeks, was examined in two big trials HPTN 083 and HPTN 084 with stunning results.
The dapivirine vaginal ring is another option for women who want a woman-controlled product. The ring is impregnated with dapivirine, which is released slowly over a month. It’s difficult to establish the exact efficacy of this product because the results weren’t as stunning as cabotegravir. It’s critical to remember that we have to listen to women about what they want, balancing what they want with the knowledge that the vaginal ring isn’t quite as efficacious.
What role do nurses play in the delivery of PrEP?
If we’re going to get prevention products into communities, we must make them simpler, and we must broaden the number and types of people who can deliver and support use. Many countries already have nurse-led PrEP services, but other countries are stricter and require physician-led services. We want to push for nurse-led services and for support from community healthcare workers, peer supporters, and lay providers, answering questions about PrEP choices and supporting people to switch, start, and stop therapy safely.
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