31st August 2018, Volume 131 Number 1481

Peter J Saxton, Massimo Giola, Edward P Coughlan, Joseph G Rich, Sunita Azariah, Adrian H Ludlam, Christy O’Toole, Mike Pohl, Jason M Myers

HIV pre-exposure prophylaxis (PrEP) is a daily pill containing tenofovir disoproxil fumarate with emtricitabine (TDF/FTC) that almost entirely eliminates the risk of HIV acquisition if taken as prescribed. On 1 March 2018 New Zealand became one of the first countries internationally to publicly fund PrEP.1 Eligible populations include gay and bisexual men (GBM) and transgender individuals at high risk, and the partners of people living with unsuppressed HIV (Figure 1). PHARMAC’s decision is timely as New Zealand’s HIV epidemic expands in size and cost.2 Substantial reductions in HIV transmission are possible; New South Wales (NSW) has witnessed a 29% decline in newly-acquired HIV diagnoses following implementation of a large PrEP demonstration project.3

Figure 1: Eligibility criteria for initiating funded HIV PrEP (1 March 2018).

Both:

1. Patient has tested HIV negative; and

2. Either:

2.1   All of the following:

2.1.1  Patient is male or transgender; and

2.1.2  Patient has sex with men; and

2.1.3  Patient is likely to have multiple episodes of condomless anal intercourse in the next 3 months; and

2.1.4  Any of the following:

2.1.4.1  Patient has had at least one episode of condomless receptive anal intercourse with one or more casual male partners in the last 3 months; or

2.1.4.2  A diagnosis of rectal chlamydia, rectal gonorrhoea, or infectious syphilis within the last 3 months; or

2.1.4.3  Patient has used methamphetamine in the last three months; or

2.2   All of the following:

2.2.1  Patient has a regular partner who has HIV infection; and

2.2.2  Partner is either not on treatment or has a detectable viral load; and

2.2.3  Condoms have not been consistently used.

PrEP may be the latest innovation in HIV prevention but is unfamiliar to most health practitioners and planners in New Zealand: we have brand new trousers, but no belt or suspenders. To achieve a good fit, we can learn from overseas programmes and replicate and adapt efficient systems locally, especially rapid scale-up. PrEP is also novel for New Zealand because it is a biomedical approach that shifts HIV prevention for HIV negative individuals from communities into the clinical setting and will therefore rely heavily on engagement by primary care, pharmacies and sexual health services.4 In this viewpoint article we review the rationale for PrEP and raise initial uncertainties about implementation.

Rationale for PrEP

PrEP is effective if taken correctly

PrEP almost entirely eliminates the risk of contracting HIV sexually if taken as prescribed. Open-label prospective cohort studies in sexual health clinics found that PrEP reduced HIV acquisition risk among GBM by 86%.5,6 With correct timing and daily adherence this risk reduction approached 99%.7 Imperfect adherence (four or more times a week) still conveyed considerable if not complete protection,8 earning PrEP a reputation for being a “forgiving” medication – which is relevant when considering “real-world” use.

Effectiveness data at the population level is emerging, with NSW recording a 29% reduction.3 London reported a 32% decline in recent HIV cases after implementing large scale PrEP services although this coincided with increased HIV testing and prompt treatment of those infected.9 Mathematical modelling studies continue to be encouraging, a recent systematic review predicting ~95% reduction in HIV transmission if PrEP is effectively targeted and combined with existing interventions.10 Indeed PrEP has recently been described as a necessary public health intervention if HIV is to be controlled.11

PrEP is timely

PrEP comes at a pivotal moment in New Zealand’s HIV epidemic. On the one hand, HIV diagnoses have been rising with the increase mostly affecting GBM.12 On the other hand we have most people living with HIV diagnosed and on treatment and unable to transmit the virus.13 We have most GBM who are susceptible to HIV using condoms for casual sex.14 And we could have the small group of people who struggle with consistent condom use for receptive anal intercourse unable to acquire HIV if they are offered, accept and adhere to PrEP.

This pincer-like prevention approach closes down opportunities for HIV to spread. PrEP, like condoms, removes users from the potential network of transmission and leaves the virus with nowhere to go, akin to herd immunity. PrEP therefore promises both private and public health benefits: protecting the user and their future sexual partners. Taken together, condoms, increased HIV testing, treating HIV, and PrEP can enable New Zealand to regain control and work towards HIV elimination.2

PrEP is moral

We can anticipate that some people will have moral objections to the government subsidising PrEP for HIV prevention. People may be concerned that it endorses risky sexual behaviour or will increase transmission of other sexually transmitted infections (STIs). However, publicly funding tools that protect against the health and social consequences of sexual behaviour is not new. PHARMAC funds the Gardasil vaccine for human papillomavirus (HPV), funds contraceptive options, and funds condoms. In July 2017 PHARMAC also removed the CD4 threshold to prescribing funded antiretroviral treatment (ART) for people living with diagnosed HIV, recognising ART’s public health value in preventing HIV transmission. To withhold public funding for PrEP would be inconsistent with these historical decisions and raise valid questions about homophobia or heterosexism, given the need for PrEP and its effectiveness, as the majority of those benefiting from PrEP would be gay and bisexual men. We believe that PrEP is the latest in a procession of innovations arising from the HIV sector and could, in time, transform practices in other public health fields.15

PrEP increases prevention options for the most vulnerable

The majority of most-at-risk individuals do use condoms for casual sex,14,16 but we need new options to prevent HIV acquisition and transmission in GBM who have difficulty sustaining condom use.17,18 Many struggle with condom use because they are vulnerable, as a result of substance addiction, poor mental health, or difficulties negotiating condom use with a sexual partner due to power asymmetry (interpersonal differences in language, age, sexual experience, openness about sexuality). Others struggle with condoms due to perceived reductions in intimacy or sensation, or because of erectile dysfunction or latex allergies. Publicly-funding PrEP can disproportionately benefit the neediest in our communities.

PrEP addresses health inequalities

Improving HIV prevention options for GBM via PrEP can help narrow health inequalities, as GBM in New Zealand are around 40 times more likely than heterosexual individuals to have HIV.19 Within GBM communities, publicly-funded PrEP can also help reduce inequalities for Māori, Pacific and Asian men, for younger men and for transgender individuals. These sociodemographic groups may face greater barriers to consistent condom use,17,20 and are likely to face disproportionate financial barriers if their only option is to pay the full price for PrEP or to import PrEP from overseas pharmacies.

PrEP can be cost-effective

PHARMAC already faces sizeable costs for New Zealand’s failure to eliminate HIV transmission, as treating HIV is lifelong and expensive. PHARMAC’s published spend on HIV antiretrovirals doubled in five years from $16 million in 2011 to $32 million in 2016 due to ongoing infections and low mortality. A well-targeted PrEP programme with high uptake will prevent HIV transmissions and limit PHARMAC’s burden. Savings can be redirected into funding other medicines and vaccines. The cost of PrEP should also decline over time as medicines come off patent and cheaper generics are negotiated. From 1 July 2018 the list price for PrEP medication Truvada™ dropped by 77% and further reductions are likely. The cost-effectiveness of a targeted programme like New Zealand’s is sensitive to the medication price, meaning PrEP could soon become cost-saving.21

PrEP can improve HIV testing and outcomes for people living with HIV

PrEP is likely to increase HIV testing among individuals most at risk. Commencing PrEP requires a confirmed HIV negative result, and only half of all GBM test for HIV annually.22 Consequently PrEP can help reduce the pool of undiagnosed HIV, estimated at 21% of GBM infected.23 Furthermore a third to a half of individuals with newly diagnosed HIV are diagnosed late (CD4 count <350).12 Individuals whose HIV is not diagnosed and treated are infectious and they play a disproportionate role in sustaining ongoing transmission in the community. Offering PrEP can engage such individuals in sexual health services resulting in earlier diagnosis and treatment. PrEP can also protect the HIV negative regular partners of diagnosed positive individuals whose virus is not fully suppressed, sharing responsibility for avoiding transmission.

PrEP can improve STI testing and treatment

Similarly, PrEP will increase the frequency and comprehensiveness of STI check-ups in a population experiencing a high burden of STIs.24 Although PrEP itself offers no protection against non-HIV STIs, each three-monthly PrEP prescription requires an STI screen. This should diagnose and treat bacterial STIs early; and help break chains of STI transmission in the community.

Expert recommendations and international experience

Finally, targeted access to PrEP in New Zealand is consistent with international recommendations from WHO, CDC and agencies in Europe, Britain and Australasia.2 Policy change also reflects the HIV Consensus Statement in Aotearoa/New Zealand25 and the New Zealand AIDS Foundation’s (NZAF) Strategic Plan 2016–19.26 A small number of countries now appear to have funded PrEP programmes (Table 1).27 Several Australian States also have large-scale PrEP demonstration projects, including NSW, Victoria and Queensland.

Table 1: National and sub-national funded PrEP programmes. Note: GBM = gay and bisexual men.

Location

Date

Funding type

Eligibility

United States

 

2014

Not public per se but criteria inform health insurance coverage

1) GBM, 2) heterosexual men and women, 3) people who inject drugsa

South Africa

 

2016

Funded PrEP offered to high risk patients

1) GBM, 2) sex workers (includes males, females, and transgendered individuals), 3) serodiscordant couples, 4) adolescent girls and young women, as per WHO guidelinesb

France

 

2016

Funded by social security and state medical aid. Majority of initial charges are fully reimbursable

1) GBM, 2) transgendered individuals, 3) people who inject drugs, 4) sex workers engaging in unprotected sex, 5) any vulnerable person who has engaged in unprotected sexc

Oslo, Norway

Nov 2016

Funded for patients attending the Olafia Sexual Health Clinic

Individuals at significant risk of HIVd

Belgium

June 2017

Heavily subsidised on reimbursement from an individual’s health insurance provider

1) GBM, 2) people who inject drugs, 3) sex workers, 4) partners of people with HIVe

 

Scotland

July 2017

Funded via Scottish NHS

1) GBM, 2) transgender individuals, 3) partners of people with HIV, 4) case-by-case on opinion of specialistf

Ontario, Canada

Sep 2017

Funded for individuals: aged under 25; Ontario Drug Benefit; Non-insured Drug Benefits Program for First Nations and Inuit. Discounted for: Private health insurance; Trillium Drug Program

1) GBM, 2) transgender individuals, 3) heterosexual men and women, 4) people who inject drugsg

Brazil

Dec 2017

Funded via 35 clinical sites

1) GBM, 2) sex workers, 3) people who inject drugsh

British Columbia, Canada

Jan 2018

Funded via BC Centre for Excellence Drug Treatment Program

1) GBM, 2) transgender individuals, 3) heterosexual men and women, 4) people who inject drugsi

New Zealand

Mar 2018

Funded via PHARMAC

1) GBM, 2) transgender individuals, 3) partners of people with HIVj

Australia

Apr 2018

Funded via Pharmaceutical Benefits Scheme

1) GBM, 2) transgender, 3) heterosexual men and women, 4) people who inject drugs, 5) case-by-case basisk

a CDC/USPHS (2014). Pre-exposure Prophylaxis for the Prevention of HIV Infection in the United States – 2014 Clinical Practice Guideline. Center for Disease Control/US Public Health Service, pp.1-11.
b World Health Organization (WHO), 2016. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. World Health Organization.
c Morlat, P. (2015). Medical management of people living with HIV: update of recommendations for pre-exposure prophylaxis (PrEP). Paris.
dOslo universitetssykehus. (2017). Olafiaklinikken. [online] Available at: http://oslo-universitetssykehus.no/avdelinger/klinikk-for-kirurgi-
inflammasjonsmedisin-og-transplantasjon/avdeling-for-revmatologi-hud-og-infeksjonssykdommer/olafiaklinikken
[Accessed 17 Feb. 2018].
e Be-prep-ared.be. (2018). PrEP in Belgium | Be Prep Ared. [online] Available at: http://www.be-prep-ared.be/en/prep-in-belgium/ [Accessed 16 Feb. 2018].
f www.prep.scot. (2018). PrEP in Scotland [online] Available at: http://prep.scot [Accessed 16 Feb. 2018].
g http://www.get-prep.com/prep-costs
hAIDSMAP. (2017). Belgium, Portugal and Brazil will provide PrEP through their health services; Morocco announces a PrEP study. [online] Available at:
http://www.aidsmap.com/Belgium-Portugal-and-Brazil-will-provide-PrEP-through-their-health-services-Morocco-announces-a-PrEP-study/page/3144551/
[Accessed 14 Feb. 2018].
i Cfenet.ubc.ca. (2018). Guidance for the use of Pre-Exposure Prophylaxis (PrEP) for the prevention of HIV acquisition in British Columbia. [online] Available at: http://www.cfenet.ubc.ca/sites/default/files/uploads/publications/centredocs/prep_guidelines_-_08jan2018.pdf [Accessed 20 Feb. 2018].
j PHARMAC. (2018). Decision to fund HIV pre-exposure prophylaxis (PrEP) | PHARMAC. [online] Available at: http://www.pharmac.govt.nz/news/notification-2018-02-07-prep/ [Accessed 14 Feb. 2018].
kASHM. (2018). HIV PrEP available on PBS in Australia from 1 April. [online] Available at: http://www.ashm.org.au/news/hiv-PrEP-available-announced-on-pbs/ [Accessed 21 Apr. 2018].
 

Implementation uncertainties

Acceptability

High risk GBM are interested in PrEP with 150 successfully enrolled in the NZPrEP demonstration project in Auckland.28 However the extent of PrEP awareness and acceptability in the broader GBM community in New Zealand is unknown and needs to be assessed and monitored. Demand for PrEP in this early phase has largely been driven by non-government agencies (NGOs) such as NZAF, through social marketing, community forums and media, in partnership with community activists and clinician-champions. This energy may not be sustainable without extra resources as it competes with condom promotion. A risk is that unbalanced marketing and advocacy will underpromote condoms, leading to behavioural risk compensation and cannibalising the prevention gains possible with PrEP.

Targets

PHARMAC estimated that 4,000 individuals would be eligible under the targeted publicly funded programme.1 Researchers have since revised this to 5,816 individuals using updated data, estimating that 17.9% of sexually active HIV negative GBM would meet the criteria.29 If 50% of GBM live in Auckland,30 2,900 need access in that city alone. Such numbers are well beyond current sexual health service capacity, meaning PrEP delivery in primary care is crucial to meeting these scale-up targets.

Prescribing bottlenecks

Identifying efficiencies in the PrEP prescribing and care process would be a valuable area of innovation. Subsidised PrEP can only be prescribed on special authority from an approved HIV prescriber, currently found on a list of specialists managed by the Ministry of Health. This numbers around 45 prescribers, most of whom presently focus on treatment of adults living with HIV, not those at HIV risk. New Zealand only has 8.0 FTE sexual health physicians, with uneven regional distribution and many DHBs not employing sexual health specialists at all or sub-contracting from other DHBs. Ten of the 20 DHBs have no-one listed as an HIV prescriber, making access to HIV care and prevention inequitable.

PHARMAC has addressed this by stating it is sufficient for a medical practitioner to have a documented recommendation from a named specialist, but it immediately raises questions about prescriber access, workload, service capacity and the consultation quality. In several centres, sexual health and infectious diseases physicians are facilitating virtual and remote consultations via e-referrals, and have developed a form for GPs to complete and return so an HIV prescriber can recommend approval if appropriate. However widening the range of PrEP prescribers at initial application, for example to include all sexual health physicians and registered medical doctors who have completed an accredited PrEP prescribing course, would better help reduce prescribing bottlenecks and improve access. 

Pharmacy delays

Many pharmacies may be reluctant to carry stock due to Truvada’s currently high list price. Anecdotally, this is resulting in further delays, on top of some patients having to wait up to a week for a special authority to be processed before they can get a prescription (pers comm “PrePing NZ” closed Facebook group). This could be mitigated by GPs with high PrEP patient caseloads developing relationships with a local pharmacy to hold stock or couriering prescriptions overnight for remote patients.

Clinic capacity

Three-monthly repeats can be prescribed by GPs and nurse practitioners who have undertaken an accredited PrEP training course, but the patient has to be seen in person for the necessary STI screening, safety monitoring and risk reduction counselling. To meet the 5,816 scale-up target, health services must seek to minimise prescribing delays and manage the increased volume of initial and three-monthly repeat in-person patient appointments. For example, a 12-month PrEP programme for 5,816 patients would require 29,080 PrEP clinical encounters nationwide (initial plus four three-monthly reviews), or around 14,540 extra encounters in Auckland. Screening, scheduling and treating STIs are not factored into this time and should not be underestimated. Sexual health service laboratory budgets may blow out due to increased NAAT testing, and high STI incidence among PrEP patients can erode clinicians’ time. Solutions include increased funding for sexual health staff and laboratory testing, and pooling laboratory specimens.

Primary care training

PrEP is also a sexual health care programme, not just a prescription. Improving primary care competencies in sexual health history taking, STI diagnosis and risk reduction counselling is fundamental as this is not currently well covered in medical or nursing training curricula. Worryingly, only half of GBM are “out” to their GP,31,32 many men report negative experiences when they do disclose their sexuality,33 and sexual orientation and gender diversity competencies are not well taught in medical school curricula.34 Addressing this will require a cultural transformation in the way primary care meets the needs of non-heterosexual and transgender patients. PrEP patients themselves have higher rates of prevalent and incident non-HIV STIs,35 hence three-monthly screening for gonorrhoea, chlamydia and syphilis infection is essential. One study estimated that 77% and 68% of STIs at three and nine months, respectively, after starting PrEP would have been missed if providers relied solely on symptom assessment.36

ASHM has published local PrEP clinical guidelines,37 the Goodfellow Unit has provided training events, and NZAF have developed patient and prescriber pamphlets and an online PrEP-prescribing “doctor map”.38 New Zealand-specific guidelines will be needed next, addressing patient eligibility, screening and safety, and workforce training courses expanded, formalised and assessed. Innovative quick-reference PrEP prescribing aids for GPs would also be welcome. These could include assessment and management of STIs in an era of changing syphilis epidemiology, antimicrobial resistance in gonorrhoea and emergence of M.genitalium. PrEP providers with low caseloads may also wish to establish prescribing peer support networks to improve clinical decision-making, especially those who are isolated geographically or professionally. Patient adherence tools such as apps could optimise PrEP’s effectiveness in practice. In Christchurch, small group teaching sessions are held where GPs undergo an online course together followed by questions and answers. The Christchurch Sexual Health Service also provides patients with “PrEP Packs”. These include swabs and diagnostic order forms, enabling patients to perform urine, pharyngeal and rectal testing at home before visiting a laboratory for blood testing, making results available within two weeks of repeat scripts.

Monitoring uptake, risk compensation, failures

The speed and scale of PrEP implementation can only be gauged by fit-for-purpose monitoring systems. Pharmacy dispensing data on Truvada special authority prescriptions will measure uptake of funded PrEP, but not self-imported generic PrEP by individuals ineligible for public funding. It is imperative that behavioural surveillance is funded among the GBM community to estimate overall PrEP uptake and, critically, uptake among GBM disaggregated by behavioural risk (eg, those eligible for PrEP) and among equity populations (eg, younger Māori, Pacific and Asian GBM). Behavioural surveillance would also evaluate whether behavioural risk compensation is emerging in response to PrEP as risk perceptions change (eg, lower condom use, more sexual partners), both among PrEP users and particularly among the wider GBM community not using PrEP.39,40 Four PrEP failures have been documented internationally41 and drug resistance is a concern, albeit low probability; these too should be anticipated and surveillance systems prepared.

Equity

PrEP should benefit those most at risk, not those most able to navigate healthcare systems. Non-European minority GBM are less likely to access and adhere to PrEP in overseas studies.42 In NSW, minority ethnic communities have experienced slower PrEP uptake and consequently the reduction in HIV has been uneven: among Australian-born GBM incident HIV declined by 49% compared to 21% among Asia-born GBM.11 In New Zealand, Māori, Pacific and Asian GBM are not more likely to acquire HIV, but evidence does suggest later diagnosis, implying barriers to clinical services. PrEP implementation here must ensure multiple entry points and appropriate follow-up, potentially including community-led and pharmacy-led delivery models, to avoid generating inequalities. Although PrEP is fully funded for those most at risk, visiting a GP every three months is not free and this will disproportionately deter some GBM.

Widening eligibility

PHARMAC’s initial funding criteria are deliberately narrowly targeted. Their origins are the ASHM “high risk” clinical guidelines which themselves are derived from an Australian cohort study.37 Eligibility for public funding should be based on need, but could in future be broadened to increase access and maximise public health benefit, presumably after the price of PrEP falls and when the issues raised by this article have been addressed. For example, the ASHM guidelines also propose “medium risk” and “case by case” categories for GBM (which would include GBM engaging in repeated insertive condomless anal intercourse with serononconcordant partner/s), and specific guidelines for people who inject drugs, transgender and heterosexual individuals. These are obvious candidates to consider in the New Zealand context. However, each country has a unique HIV epidemiology, and decisions about widening eligibility should be based on evidence to avoid wasting public funds.

Ineligible patients

Temporary migrants who meet the PrEP behavioural risk criteria are not however eligible for funded healthcare. Notably this includes international students, a sexually active population many of whom may have chosen to study in New Zealand because of our progressive laws and social acceptance of homosexuality. Other patients, ineligible for public funding because they fail to meet the behavioural criteria can still be prescribed the medication and then purchase PrEP unsubsidised at $250-$350 per month. Importing generic versions of PrEP from trusted overseas pharmacies is a popular alternative option and costs as little as $70 per three-month supply.43 These provide an alternative avenue for individuals who still feel at risk of HIV and could benefit from PrEP.

Promoting confidence in condoms

Why do otherwise low-risk patients feel so vulnerable to HIV? Is it overestimation of personal risk? Or lack of confidence in condoms? Promoting the value of pharmaceuticals such as PrEP should not result in scaring people or exaggerating HIV risks, making GBM feel powerless or that they lack agency without the medication, or that effective interventions such as condoms are now inadequate, passé or unsophisticated.

In New Zealand, local HIV transmission is concentrated among GBM who account for 89% of diagnoses.12 Condoms prevent transmission 100% of the time if used consistently and correctly and they remain intact.44 Condoms also possess many qualities not shared by PrEP, such as reducing transmission of undiagnosed STIs which are endemic among sexually-active GBM, and being visually verifiable, meaning sexual partners don’t have to rely on full and accurate disclosure of sexual history, STI and medication status prior to casual sex.15 These messages should be reinforced in consultations with patients, safe sex social marketing and in policy formulation.

Policy

At the time of writing the Government had no HIV or sexual health action plan to guide planning, workforce training, delivery or research into PrEP. Jurisdictions such as NSW cite government leadership as central to their rapid successes in deploying PrEP, including aspirational targets with short time frames (eg, Ending HIV by 2020). Here, DHBs and PHOs will also play an important role by ensuring that sexual health services have adequate capacity and expertise and by training primary health care to be PrEP-ready.

Conclusion

Now that biomedical PrEP for HIV prevention is funded, we should aim to implement it with a “hit early and hit hard” mentality. Non-biomedical community-based and behaviour-change approaches like condom use should continue and PrEP should be matrixed within these. That promises the best impact but requires a short-term, deliberate, focused and energetic response across the health sector, not merely HIV and sexual health agencies alone. After sustained annual increases, new HIV diagnoses in 2017 declined by 21% — a glimpse of what’s possible.12 International observers will be watching to see if New Zealand displays the same verve behind implementing PrEP as we did to fast-track funding. Let’s not get caught with our pants down.

Summary

PrEP is a hugely promising new tool in the HIV prevention toolkit but it won’t stop transmission if it’s sitting on the shelf. Our concern is that people most at risk of HIV don’t know about PrEP; sexual health clinics are struggling from underfunding; GPs aren’t offering PrEP to their eligible patients; and we aren’t monitoring PrEP roll-out well enough. HIV diagnoses have been rising in NZ so getting PrEP implementation right is critical. Our grave concerns about slow PrEP implementation are reflected in two recent news stories: the congenital syphilis scandal; and poor coverage of sexuality in medical school curricula.

Abstract

HIV pre-exposure prophylaxis (PrEP) is a daily pill that prevents HIV acquisition. In March 2018, New Zealand became one of the first countries in the world to publicly fund PrEP for individuals at high risk. PrEP promises significantly improved HIV control but is unfamiliar to most health practitioners here, compromising its potential. In this article we review the rationale for PrEP and identify barriers to rapid implementation. The latter include: consumer and health practitioner awareness; acceptability; scale-up targets; prescribing and pharmacy bottlenecks; service capacity to manage follow-up; primary care training; monitoring systems for uptake and quality; equity; eligibility; risk compensation and policy. Many of these areas are ripe for research and innovation. By addressing these obstacles we can realise the potential of PrEP and move closer to ending HIV in Aotearoa/New Zealand.

Author Information

Peter Saxton, Director, Gay Men’s Sexual Health Research Group, Department of Social and Community Health, University of Auckland, Auckland; Massimo Giola, Infectious Diseases Specialist and Sexual Health Physician, Tauranga Hospital, Tauranga; Edward Coughlan, Director, Christchurch Sexual Health Service and President, New Zealand Sexual Health Society, Christchurch ;
Joe Rich, Operations Director, New Zealand AIDS Foundation, Auckland;
Sunita Azariah, Sexual Health Physician, Auckland Sexual Health Service, Auckland;
Adrian Ludlam, Policy and Science Manager, New Zealand AIDS Foundation, Auckland;
Christy O’Toole, Year 5 Medical Student, University of Auckland, Auckland;
Mike Pohl, General Practitioner, Auckland; Jason Myers, Executive Director, New Zealand AIDS Foundation, Auckland.

Acknowledgements

The New Zealand AIDS Foundation Fellowship funded Dr Saxton’s time on this work. The authors acknowledge the efforts and perspectives of many HIV and sexual health clinicians, GPs, NGO staff and gay community members surrounding PrEP in New Zealand that have informed this viewpoint.

Correspondence

Dr Peter Saxton, Department of Social and Community Health, University of Auckland, Private Bag 92109, Auckland.

Correspondence Email

p.saxton@auckland.ac.nz

Competing Interests

Gilead Sciences has funded study medication, extra laboratory costs and a research nurse on the separate NZPrEP demonstration project at Auckland Sexual Health Service (lead PI Dr Azariah). PHARMAC has provided salary support for behavioural analysis on NZPrEP (Dr Saxton).

References

  1. http://www.pharmac.govt.nz/news/notification-2018-02-07-prep/ 
  2. Saxton P, Hughes A, Giola M. HIV prevention today: with coordinated action, we can end transmission. N Z Med J. 2015; 128:8–15.
  3. http://www.health.nsw.gov.au/endinghiv/Publications/q4-2017-and-annual-hiv-data-report.pdf
  4. Zablotska IB, O’Connor CC. Preexposure Prophylaxis of HIV Infection:the Role of Clinical Practices in Ending the HIV Epidemic. Current HIV/AIDS Reports. 2017; 14(6):201–10.
  5. McCormack S, Dunn D, Desai M, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet. 2016; 387:53–60.
  6. Molina J, Capitant C, Spire B, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015; 373:2237–46.
  7. Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Science translational medicine. 2012 Sep 12; 4(151):151ra125.
  8. Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014; 14:820–9.
  9. Brown AE, Mohammed H, Ogaz D, et al. Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)? Eurosurveillance. 2017; 22(25).
  10. Zablotska IB. Likely impact of pre-exposure prophylaxis on HIV epidemics among men who have sex with men.Sexual health. 2017; 14(1):97–105.
  11. Grulich A, Guy RJ, Amin J, et al. Rapid reduction in HIV diagnoses after targeted PrEP implementation in NSW, Australia. Paper presented at CROI, Mar 4–7, 2018, Boston.
  12. AIDS Epidemiology Group. AIDS – N Z. Issue 77 June 2017.
  13. Raymond N, Bargh K, Aung KL, Rice J. Cascade of care for people living with HIV infection in the Wellington region. N Z Med J. 2016; 129:41–51.
  14. Saxton P, Dickson N, Hughes A. Condom use stable and more HIV testing: location-based HIV behavioural surveillance among MSM in Auckland, New Zealand 2002–2011. Sexually Transmitted Infections. 2014; 90(2):133–138.
  15. Hughes A, Saxton P. Thirty years of condom-based HIV prevention among gay men in New Zealand. N Z Med J. 2015; 128(1426):8–15.
  16. Saxton P, Dickson N, Hughes A. Trends in web-based HIV behavioural surveillance among gay and bisexual men in New Zealand: Complementing location-based surveillance. AIDS Care, 2015; 27:762–766.
  17. Saxton P, Dickson N, Hughes A, Ludlam A. Infrequent condom use with casual partners among New Zealand gay and bisexual men. N Z Med J, 2015; 128(1426):815.
  18. Neville S, Adams J, Moorley C, Jackson D. The condom imperative in anal sex–one size may not fit all: A qualitative descriptive study of men who have sex with men (MSM). Journal of Clinical Nursing. 2016 online first.
  19. McAllister SM, Dickson NP, Sharples K, et al. Unlinked anonymous HIV prevalence among New Zealand sexual health clinic attenders: 2005–2006. International Journal of STD & AIDS. 2008; 19(11):752–7.
  20. Neville S, Adams J. Views about HIV/STI and health promotion among gay and bisexual Chinese and South Asian men living in Auckland, New Zealand. International Journal of Qualitative Studies on Health and Well-being. 2016; 11(30764). doi: 10.3402/qhw.v11.30764
  21. Cambiano V, Miners A, Dunn D, et al. Cost-effectiveness of pre-exposure prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study and health economic evaluation. The Lancet Infectious Diseases. 2018; 18:85–94.
  22. Saxton P, Dickson N, Hughes A, Ludlam A. GAPSS/GOSS Research Brief: HIV testing among gay and bisexual men. Auckland: The University of Auckland, 2015.
  23. Saxton P, Dickson N, Griffiths R, Hughes A, Rowden J. Actual HIV prevalence and undiagnosed infections in a community sample of men who have sex with men in Auckland, New Zealand. BMC Public Health, 2012; 12:92.
  24. Dickson N, Ludlam A, Saxton P, Hughes A. Self-reported STIs and sexual health checks in a cross-sectional study of gay and bisexual men in New Zealand. Sexually Transmitted Infections, 2015; 91(1):49–54.
  25. http://hivconsensus.org.nz/ 
  26. http://www.nzaf.org.nz/assets/ee-uploads/files/161205_NZAF_Strategic_Plan_2016-2019.pdf 
  27. O’Toole C. National or Subnational Pre-Exposure Prophylaxis (PrEP), Eligibility for Access to Funded PrEP: a literature review. Auckland: Faculty of Medical and Health Sciences 5th Year Medical Student Practicum. University of Auckland, 2018.
  28. Saxton P, Azariah S, Franklin R, Forster R, Werder S, Jenkins R, Myers J, Rich J, Te Wake W, Fisher M. Baseline characteristics of gay and bisexual men in an HIV pre-exposure prophylaxis demonstration project with equity quotas in Auckland, New Zealand. Sexual Health Online First http://www.publish.csiro.au/SH/justaccepted/SH18056
  29. Saxton P, McAllister S. Enumerating the population eligible for funded HIV pre-exposure prophylaxis (PrEP) in New Zealand. Manuscript under review.
  30. Hughes A, Saxton P. Geographic micro-clustering of homosexual men: Implications for research and social policy. Social Policy Journal of NZ, 2006; 28:158–178.
  31. Ludlam A, Saxton P, Dickson N, Hughes A. General practitioner awareness of sexual orientation among a community and Internet sample of gay and bisexual men in New Zealand. Journal of Primary Health Care, 2015; 7:204–212.
  32. Adams J, Neville S. Exploring talk about sexuality and living gay social lives among Chinese and South Asian gay and bisexual men in Auckland, New Zealand. Ethnicity & Health. 2018; 1-17. doi:10.1080/13557858.2018.1439893
  33. Adams J, McCreanor T, Braun V. Doctoring New Zealand's gay men. NZ Med J. 2008; 121(1287): 11–20.
  34. Taylor O, Rapsey C, Treharne G. Sexuality and gender identity teaching within preclinical medical training in New Zealand: content, attitudes and barriers. N Z Med J. 2018; 1477:35–44.
  35. Traeger MW, Schroeder SE, Wright EJ, et al. Effects of Pre-exposure Prophylaxis for the Prevention of HIV Infection on Sexual Risk Behavior in Men Who Have Sex with Men: A Systematic Review and Meta-analysis. Clinical Infectious Diseases. 2018
  36. Golub SA, Peña S, Boonrai K, et al. STI data from community-based PrEP implementation suggest changes to CDC guidelines. 23rd Conference on Retroviruses and Opportunistic Infections Boston, Massachusetts, 2016 Feb 22.
  37. Wright E, Grulich A, Roy K, et al. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine HIV pre-exposure prophylaxis: clinical guidelines. Journal of virus eradication. 2017; 3:168.
  38. http://endinghiv.org.nz/stay-safe/prep/prepmap
  39. Holt M, Lea T, Mao L, et al. Adapting behavioural surveillance to antiretroviral-based HIV prevention: reviewing and anticipating trends in the Australian Gay Community Periodic Surveys. Sexual Health. 2017; 14:72–9.
  40. Holt M, Lea T, Mao L, et al. Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013–17. The Lancet HIV. 2018 Online first. https://doi.org/10.1016/S2352-3018(18)30072-9. 
  41. Hoornenborg E, de Bree GJ. Acute infection with a wild-type HIV-1 virus in a PrEP user with high TDF levels. Poster presented at CROI, 2017, Feb 13–16, Seattle.
  42. Liu A, Cohen S, Vittinghoff E, et al. Preexposure prophylaxis for HIV infection integrated with municipal-and community-based sexual health services. JAMA Internal Medicine. 2016; 176:75–84.
  43. www.endinghiv.org.nz/prep 
  44. Barre-Sinoussi F, Abdool-Karim S, Albert J, et al. Expert Consensus Statement on the Science of HIV in the Context of the Criminal Law. Journal of the International AIDS Society. 2018; Online First