"The anti-AIDS pill works, let's make it better known"

The French PrEP specialist explains the challenges of this new mode of prevention.
  

Head of the Department of Infectious and Tropical Diseases at the Saint-Louis Hospital (AP-HP) in Paris, Professor Jean-Michel Molina has contributed significantly to the development of PrEP (Pre-exposure Prophylaxis), a drug that protects against HIV infection. On the occasion of the world congress against AIDS that was held in Amsterdam from July 23 to 27, this researcher published a new study confirming the effectiveness of this "chemical condom". He is now calling for wider communication around this new means of prevention. With hope: finally curbing the dynamics of the epidemic.

It was difficult to escape PrEP this week: posters in the Paris metro, headlines in the newspapers as a result of your study … Can you remember what this treatment is?

Originally, it is one of the components of tritherapies used for more than fifteen years to keep infection under control in patients already infected with HIV. Originally marketed as Truvada, but now available as a generic, this antiviral has been diverted from its original purpose for use in prevention. It prevents the virus from entering the cells of the exposed person, who will not be infected. Men can take treatment daily or only during unprotected bad. For women, only long-term feeding is recommended at this stage.

You had already demonstrated the effectiveness of PrEP in a clinical trial in 2015. What does the study presented this week bring?

We have this time followed "in real life" 1625 volunteers in the Paris region, between May 3, 2017 and July 2, 2018. The objective was to know if patients would adhere to the proposed treatment scheme, and come to mandatory appointments every three months. This is an essential point, because in case of non-compliance with the recommendations (forgetting the pill …), the risk of contamination is real. And it works: there was no infection in this population. This is very good news, because it confirms the effectiveness of PrEP in the "real life" and opens the possibility of breaking the dynamics of the epidemic, by limiting the number of new infections. For ten years, this one stagnates around 6000 cases per year. It's way too much, we have to do better.

You talk about stemming the epidemic, not eradicating it. Do not you think that's an achievable goal today?

No, because for that, we would also need a vaccine, and a medicine to cure the already infected people, in whom the virus stagnates in some cells in the dormant state, ready to reappear as soon as therapies are stopped. On the other hand, PrEP should still curb the spread of HIV, especially in groups at risk of being exposed to newly infected individuals. In this case indeed, the virus can take a few days to a few weeks to be detected by serological tests, even the most sophisticated. The infected person can transmit it without his knowledge, all the more easily as it is also during this period that HIV proves the most contagious. PrEP – like the condom – offers the opportunity to protect yourself in this type of situation. But above all, we rely heavily on PrEP to renew the discourse on prevention, which has been dulling in recent years. This is the paradoxical effect of therapeutic progress: today AIDS is less scary, and the use of screening and condoms is loosening.

Exactly, are not you afraid that the spread of PrEP further contributes to this phenomenon, and also amplifies the spread of other badually transmitted infections (STIs)?

Of course, this problem should not be ignored, but other STIs are not life-threatening, and most are easily treated within days or weeks of antibiotic therapy. What is the priority? The same question would arise if an AIDS vaccine were available today. In addition, PrEP involves rigorous medical monitoring, with appointments every three months. On this occasion, screening tests are carried out, of HIV, but also of STIs. This makes it possible to identify STIs at a pre-symptomatic stage, to treat them very early and to prevent their spread. So, on the contrary, PrEP could help reduce their incidence. It is not a question of opposing the drug to the condom anyway: they complement each other, and should ideally be used at the same time.

PrEP today mainly concerns the homobadual community. Should its use be expanded?

The effectiveness of this treatment argues for better knowledge. About 8000 people take it today, 98% of gay men. A greater number of them would probably benefit from it. Beyond this, populations from areas where the virus is endemic – sub-Saharan Africa, Latin America, Southeast Asia – are most affected by new infections. The National Agency for Research on AIDS and Hepatitis has conducted several surveys of these audiences, and it turns out that some women in particular are very interested in this means of prevention. Transgender people, drug addicts and prostitutes must not be forgotten either. Taken together, these different populations represent about 80% of new HIV diagnoses in France.

Beyond this, should PrEP be offered to all individuals with "at risk" behaviors?

This is a delicate question. Condoms remain an effective means of preventing HIV and other STIs, and this message needs to continue, especially among young people. But by communicating widely about PrEP, it helps to remember that AIDS still exists, that it must be protected, and that there is now a new and effective method of prevention. Then everyone, in consultation with their doctor, to make the choice best suited to their needs. From this point of view, the communication campaign launched by the badociation Aides seems to me very beneficial. It will probably be necessary to go further in the future, to raise the awareness of a wider audience.

Does PrEP evolve?

Several laboratories are working on new routes of administration of this treatment: gels or badl rings that women would keep a month, injectable products with an effectiveness of two or three months, implants valid for a year or two .. The more options we have, the more prevention will be used and the better we can control this outbreak. We all have to win.