New recommendations for HIV pre- and post-exposure preventive treatment: interview with Dr Arvieux

What are the aims of the new PrEP recommendations?

Towards expanding the indications for PrEP

HIV pre-exposure prophylaxis (PrEP) is a fully-fledged tool in the strategy for preventing HIV infection, and its effectiveness has been demonstrated. However currently in France, most people diagnosed with HIV infection have identifiable exposure factors, which should have led to them being prescribed PrEP to prevent infection. We therefore need to broaden the indications, focusing of course on people at greatest risk of exposure, but also responding to requests from people who do not report any obvious excess risk of exposure: the decision to start PrEP must be a shared one.

Facilitating access to PrEP

A crucial point in these recommendations is to try to widen access to PrEP for young women from sub-Saharan Africa, a population heavily affected by HIV but under-represented among PrEP users. Broadening the range of prescribers to include professionals such as midwives is also envisaged as a way of facilitating access. In addition, the forthcoming introduction in France of injectable cabotegravir, administered every two months, could provide an additional PrEP opportunity for these women. The recommendations emphasise the simplicity of prescribing and monitoring PrEP, which no longer requires hospital consultation, and stress its proven efficacy.

What are the indications for post-exposure prophylaxis (PEP)?

After high-risk sexual or blood exposure, post-exposure prophylaxis (PEP) can reduce the risk of HIV transmission.

PEP is prescribed when there is a proven risk of HIV transmission, i.e. when a source person has a detectable viral load. However, in France, the majority of HIV-positive people being monitored have an undetectable viral load, thereby reducing the risk of transmission. The “reservoir of risk” is therefore essentially made up of people who are not yet aware of their seropositivity. PEP is particularly recommended in high-risk situations, such as unprotected anal sex with men who have sex with men (MSM) or transgender women whose HIV status is unknown.

The French recommendations have adopted the same model as that which guided the UK recommendations, where treatment is recommended if the number of people to be treated to avoid infection is less than 10,000. If this number is between 10,000 and 100,000, treatment is to be discussed, and above 100,000, it is not recommended. For example, for vaginal intercourse, PEP is almost never indicated. However, in the case of anal intercourse unprotected by a condom with an MSM or trans person of unknown HIV status, it is systematically indicated.

However, as with PrEP, given the very good tolerance of post-exposure treatments, there is no reason to refuse an EIP to a person who considers it essential for their health, after explaining the benefit-risk balance of the treatment and the levels of risk as set out above.

How are PEP and PrEP linked?

Although not very effective on a large scale as a public health tool, PEP remains important for certain patients and can be a gateway to PrEP. It is therefore advisable to discuss PrEP with anyone presenting for an EIPT, and to switch directly to PrEP after the EIPT if the exposed person’s situation shows that exposure may be repeated. The transition is made easier by the fact that the molecules offered for oral PrEP and for PEP are very similar. It is now recommended that anyone who has been on PEP for 28 days and wishes to switch to PrEP should do so without interruption, even if this means measuring the viral load at the end of PEP if there is any doubt about a primary infection.

The recommendations focus on the choice of treatments that are effective, well tolerated and as inexpensive as possible.