Most at risk populations for HIV – is there a role for PrEP in the preventive armamentarium

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Eligibility for Pre-exposure Prophylaxis According to Different Guidelines in a Cohort of HIV-Negative Men Who Have Sex with Men in Lisbon, Portugal

Publication . Meireles, Paula; Plankey, Michael; Rocha, Miguel; Rojas, Jesus; Brito, João; Barros, Henrique

Objectives Defining eligibility for preexposure prophylaxis (PrEP) is key to measuring the degree of PrEP implementation. While the clinical exclusion criteria are identical across different guidelines, definitions of substantial HIV risk are not. In this study, we aimed to estimate the proportion of men who have sex with men (MSM) being tested at a community-based voluntary human immunodeficiency virus (HIV) counseling and testing center in Lisbon that would be eligible for PrEP according to guidelines from the World Health Organization (WHO), the US Public Health Service and Centers for Disease Control and Prevention (US-CDC), the European AIDS Clinical Society (EACS), and the Portuguese National Health Service (PNHS). Methods We used baseline data from 3392 HIV-negative MSM with valid information on eligibility for PrEP enrolled in the Portuguese Lisbon Cohort of MSM—an observational study designed as an open prospective, noninterval cohort—between March 2014 and March 2018. Results At baseline, the proportion of MSM eligible for PrEP was 67.7% according to the US-CDC, 60.6% according to the PNHS guidelines, 58.9% according to the WHO, and 46.5% according to the EACS guidelines. The most frequently met criteria were those related to condomless anal intercourse. Conclusions In conclusion, in the same population, the proportion of men eligible for PrEP differed by guideline, ranging from 46.5% to 67.7%, though if they all seem to include the same well-known predictors of HIV seroconversion. Policy implications These results show that both the allocation of resources and the approaches to individual risk prediction are highly dependent on the chosen guideline. Moving the focus from assessing risk to assessing whether PrEP is a suitable option for a given individual in a given moment of his life might help to overcome guidelines limitations and create more equitable access.

2020-01-03Journal article

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Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014-2018

Publication . Paula Meireles (141F-CCDF-0735); Michael Plankey; Rocha, Miguel; João Brito; Luís Manuel Penim Mendão (AA16-B94D-A1A0); Henrique Barros (4E1A-FE7A-C959)

Introduction Guidelines for pre-exposure prophylaxis (PrEP) provide criteria to identify individuals at higher risk of HIV infection. We compared the ability to predict HIV seroconversion of four guidelines: the World Health Organization (WHO), the United States Public Health Service and Centers for Disease Control and Prevention (US CDC), the European AIDS Clinical Society (EACS) and the Portuguese National Health Service (PNHS). Aim We aimed to measure the association between guideline-specific eligibility and HIV seroconversion. Methods We studied 1,254 participants from the Lisbon Cohort of men who have sex with men with at least two evaluations between March 2014 and March 2018, corresponding to 1,724.54 person-years (PY) of follow-up. We calculated incidence rates (IR) according to each guideline eligibility definition and incident rate ratios (IRR) to test the association between eligibility at baseline and HIV seroconversion. Results We found 28 incident cases (IR: 1.62/100 PY; 95% confidence interval (CI) 1.12–2.35). Guidelines’ sensitivity varied from 60.7% (EACS) to 85.7% (PNHS) and specificity varied from 31.8% (US CDC) to 51.5% (EACS). IR was highest among those defined as eligible by the PNHS guideline (2.46/100 PY; IRR = 4.61; 95% CI: 1.60–13.27) and lowest for the WHO guideline (1.89/100 PY; IRR = 1.52; 95% CI: 0.69–3.35). Conclusions Being identified as eligible for PrEP was associated with a higher risk of infection. The magnitude of risk varied according to the guideline used. However, the number of HIV infections identified among ineligible participants highlights the potential for missing people who need PrEP.

2020-07-16Journal article

Open access

Provision of Preexposure Prophylaxis at the Portuguese National Health Service and Uptake in the Lisbon Cohort of Men Who Have Sex with Men

Publication . Meireles, P.; Fernandes, F.; Rocha, Miguel; Plankey, M.; Barros, H.

We aimed to study the uptake of preexposure prophylaxis (PrEP) before and after its implementation in the Portuguese National Health Service (PNHS) among men who have sex with men (MSM). We studied 6164 participants in the Lisbon Cohort of MSM who participated between March 2014 and July 2019. 198 participants (3.2%) reported having recently used PrEP. Approximately one-third started PrEP after its implementation. PrEP uptake increased from 0.15% in 2014 to 5.36% in 2019. In their first use, 86 participants (70.5%) used it daily. How PrEP was obtained varied according to the timing of the first use: prescribed by a physician in Portugal (11.1% before vs 68.8% after implementation) and online (40.7% before vs 14.1% after). We observed an increase in the uptake and in the prescription by a physician, particularly after its implementation in the PNHS representing a change to a more equitable and safer way of using PrEP.

2021Journal article

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