SEATTLE — An essential function of the public health sphere is the identification of risks. Understanding which genetic traits, behaviors or environmental factors increase an individual’s susceptibility to disease can help health workers provide appropriate care. When doctors ask you about your family history, diet, cigarette use or sexual activity, they are looking to identify risk factors that can predispose you to certain health problems. In doing so, they can also help you take preventative measures to protect yourself.
HIV/AIDS, in particular, is one disease upon which treatment relies heavily on risk assessment and prevention. Scientists know now that HIV/AIDS is spread through bodily fluids; and transmittable through sex, intravenous drug usage and pregnancy. AIDS is caused by the progression of HIV destroying the immune system’s ability to fight infection.
While there is no cure, several treatments for HIV/AIDS have emerged. Today, there are over 30 different antiretroviral drugs (ARVs) on the market to suppress HIV infections. If taken every day for a number of years, antiretrovirals allow individuals with HIV to live longer and healthier lives.
The problem is, HIV/AIDS is most endemic in areas that lack the healthcare infrastructure to provide ARVs to those in need. Out of the estimated 36.9 million people living with HIV, 70 percent live in sub-Saharan Africa. Once diagnosed, treating this many people places an extreme financial burden on the public health sphere — roughly $23 million was required for treatment in 2015 alone. Shifting the focus from treatment to prevention could be both cost-effective and a way to prevent HIV in the first place.
Pre-exposure Prophylaxis, or PrEP, is medication for people who do not have HIV but, for whatever reason, are at an increased risk of the disease. Taken once a day, PrEP delivers a dose of ARVs that can protect at-risk people from becoming infected. In the U.S., the population at risk primarily includes men who have sex with men and intravenous drug users. Worldwide, at-risk populations include not only these two populations, but also men who are incarcerated or were formerly incarcerated, and sex workers.
Although AIDS mortality is in steady decline, the World Health Organization maintains that at-risk populations are not receiving equal care. Only 70 percent of the countries surveyed explicitly met the healthcare needs of men who have sex with men and sex workers. For drug users, that number drops to 40 percent. Additionally, national HIV treatment policies rarely include transgender people. So, even if a proper healthcare policy exists in writing, maintaining the health infrastructure necessary to deliver care continues to be a global challenge.
These numbers show that as more people become infected, the difficulty of providing care also increases. This is the rationale behind PrEP, which is the first drug of its kind created to prevent HIV in the first place. Recent studies show its astounding success. In fact, a study conducted by Kaiser Permanente in San Francisco found that PrEP prevented HIV in 100 percent of 600 “high-risk” individuals.
But is PrEP a viable solution in other countries? Even more importantly, is PrEP feasible in low-resource countries with limited health infrastructure? Currently, PrEP is only available to the public in the United States, though several other countries are running randomized trials.
Generic versions of Truvada, the antiretroviral approved for PrEP, are available for many low and middle-income countries. However, without increased donor support and newer models of provision, many countries would need to make unfair trade-offs with other HIV prevention methods in order to afford PrEP.
There are several questions to consider for possible PrEP users:
1. Is this person at high enough risk to benefit from pre-exposure antiretrovirals?
2. Will this person take the pill every single day as prescribed to be effective?
3. Can this person meet regularly with a doctor to refill their prescription and stay up-to-date on emerging information?
Until the answer to such questions is a clear “yes,” PrEP may not be the best solution for at-risk populations in countries with limited resources. Nonetheless, the immediate success of PrEP in the U.S. shows hope for prevention-oriented approaches to HIV/AIDs.
– Jessica Levitan