PrEP pilot January


PrEP pilot January

Health ministry to roll out HIV prevention drugs

Senior staff reporter

Sunday, December 01, 2019

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AS of January next year, select Jamaicans will have access to pre-exposure prophylaxis (PrEP), a type of drug used to prevent human immunodeficiency virus (HIV) infection.

Dr Nicola Skyers, senior medical officer in the HIV/Sexually Transmitted Infection (STI)/Tuberculosis Unit of the health promotion and protection branch at the Ministry of Health and Wellness, told the Jamaica Observer that the ministry is in the process of developing a PrEP programme and will start a small-scale pilot in the new year.

According to the Centres for Disease Control and Prevention (CDC), the drug PrEP is a way for people who do not have HIV, but are at very high risk of getting HIV, to prevent infection by taking a pill every day. Currently, the health and wellness ministry offers antiretroviral therapy (ART) to HIV-positive individuals.

Dr Skyers explained that though the drug has been used in other countries and is proven to work, it still has to be piloted locally as a measure of best practice.

“You can't just take up something out [of] the USA, Africa or elsewhere and drop it in a country like that. You have to see how it works in the space, and that is what our 2020 start-up will be like, to see how we can bring it to scale within our context,” the senior medical officer said.

Further, Dr Jennifer Brown-Tomlinson, HIV clinician at Jamaica AIDS Support for Life (JASL), pointed out that PrEP implementation goes beyond just taking a pill, as adherence to medication is a major challenge in treating HIV-positive individuals.

“One major problem is adherence to medication. If a diabetic falls off their treatment and goes back on [it] a year later, they're fine. But if you are HIV positive and miss more than one treatment per month, you very quickly develop resistance.

“[Further], you can't pop a pill the day after and think you won't be infected. It's more than taking a tablet,“ Dr Brown-Tomlinson insisted. “We have to monitor them for regular HIV checks [and] monitor them for side effects for the medication. It's a programme that has to be developed and the foundation public education is also necessary.”

She added: “It's not a matter of writing a prescription and sending the client to get it. It needs regular monitoring — monitoring the client for STI, the client has to be monitored for adherence to medication, monitored for side effects of the medication, they need to have regular HIV checks. If you have a client taking PrEP and not adhering to the medication, and then they become exposed to HIV and become HIV positive, that medication they were not adhering to, I can't now give it to them as treatment because they are now going to be resistant to treatment.”

Similar sentiments were shared by Dr Kevin Harvey, Caribbean regional director at AIDS Healthcare Foundation (AHF), who welcomed the pilot but said that AHF would not be offering PrEP on a wide-scale basis.

“We will not be rolling out PrEP as a wide-scale thing. It is very specific, in terms of how it is used. If we are saying patients can't adhere to treatment for their own health, then negative people are going to adhere to PrEP?” Harvey asked.

Dr Harvey said, too, that while there is no issue with whether the drug works, it has limitations that must be treated delicately.

“PrEP works. There is no issue with that, but remember PrEP is not for everyone. Undetectable equals untransmittable. PrEP is for someone negative who is having sex with someone who is positive. We're giving the negative persons pills to prevent him from getting infection from the positive person. But if we could control the positive person who needs the treatment, we're saying that you can't pass it on. So why are we not focusing on treating the positive rather than PrEP?

“PrEP has a use, as there are some couples where the relationship is not equal and you can't make the decisions in the relationship — you can't tell the man to use a condom and so on. There are some persons who are on the streets and they are selling sex and may be negative. In certain conditions, PrEP is very useful, but really, if you could treat the HIV-positive [individuals], that would be better. So it is useful, but in a limited way,” Dr Harvey explained.

Dr Brown-Tomlinson also raised questions about the locations at which PrEP drugs would be made available in order to ensure adherence.

“The question is, do you have PrEP at the treatment sites or health centres? If only at treatment sites, you're saying a person not HIV positive has to go to a treatment site to get it, and there are already issues with stigma,” she pointed out.

Besides PrEP, concerns were also raised about the availability of post-exposure prophylaxis (PEP) locally, and whether there were plans to have it available over the counter.

The CDC's website explains that PEP means taking antiretroviral medicines after being potentially exposed to HIV, to prevent becoming infected.

The website further states that PEP should be used only in emergency situations and must be started within 72 hours after a possible exposure to HIV.

But while PEP is available for occupational and non-occupational exposure to HIV, its toxicity and specificity for use prevents it from being available over the counter.

“PEP is in the national guidelines and is available for occupational and non-occupational exposure. Occupational exposure [is] for those who have been exposed through needle stick and non-occupational [is] for those sexually assaulted. Every treatment site is supposed to have a stock of PEP that is there and not to be dispensed, unless necessary,” Dr Brown-Tomlinson said.

“It's not an over-the-counter drugs. These drugs are not simple drugs and can have side effects. Using them over the counter, without monitoring, will cause resistance virus,” Dr Harvey added.

On the issue of resistant HIV viruses, Dr Brown-Tomlinson said it is a global issue; however, locally, concern must be given.

“Some clients are already resistant to medication before they even start treatment. This means the virus they were exposed to was already resistant. It is enough of a concern that the Government has started resistant testing. Right now, clients not responding to medication, we monitor them to ensure they are adhering, doing everything, [and] if they are still not doing well, we look at resistance testing,” she said. “It is an issue and something being monitored by the national programme.

“It is important [because] in the space of five years, a patient can become resistant to everything we have to offer, and then what? They themselves start to transmit resistant virus, and so it can become a problem. This is why compliance and adherence is a big issue,” the HIV clinician insisted.

With regards to PEP, Dr Harvey said AHF offers the treatment if there is a need.

“If someone comes in and they have been exposed, even if they are not sure and we can't test the other person to prove that they are negative, we will give PEP. PEP is very useful and it should be used. It started in the health care setting for persons who would have had needle sticks. It's there,” he said.

In the meantime, JASL has highlighted challenges with treatment for HIV patients who have other ailments.

“We don't lack for ART medication. The challenge is getting access to the other treatment service the clients might need, whether it be investigations, sometimes patients need MRI (magnetic resonance imaging), CT (computerised tomography) scans, X-rays, ultrasounds, and also treatments of other co-morbid conditions. Our clients, as they get better, their high blood pressure becomes a problem, diabetes become a problem, and our clients don't have access to the medication available to others in the Government service, so that also becomes a challenge. As patients do better in terms of HIV, their co-morbid conditions become an issue.

“Patients who attend Government health centres can go to the pharmacy and collect anti-hypertensive and diabetic medications free of cost. We don't have that facility, so our patients have to buy their medication. Even if they have NHF (National Health Fund), it pays a portion at private pharmacy,” Dr Brown-Tomlinson said.

World AIDS Day is being commemorated today under the theme 'Communities make the difference'. This year marks 36 years since the discovery of HIV.

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