PrEP and Related Interventions for Key Populations

Chris Beyrer, of the International AIDS Society and Johns Hopkins University, delivered a keynote presentation on interventions to address HIV among key populations in the United States.

Beyrer began by pointing out that, world-wide, 37,000,000 people are living with HIV and only 37-38% are on antiretroviral therapy. At the time of his presentation, only three countries – the United States, Thailand and Malaysia – had implemented PrEP, and none had done so through national health systems.

Just ahead of the Summit, Kaiser Permanente released data from a longitudinal study of 650 people living in San Francisco who had been prescribed PrEP, among whom there were zero new infections. “This is a tool that has the potential to make a difference,” Beyrer said. However, he noted that only a select group of people could afford the insurance plan study participants were on.

During a Q&A session after his presentation, Beyrer added that Truvada has so far shown side-effects related to bone density and kidney function, and that people considering PrEP need to be screened and monitored for potential complications. For people who already have HIV, mistakenly taking PrEP can lead to drug resistance. Beyrer emphasized the need to run extremely sensitive HIV tests before prescribing PrEP, and explained that this is a barrier to introducing PrEP in low-income settings.

What key populations are… for example, 70% of new infections in the United States. This is the epidemic. There isn’t some other epidemic.

Throughout his presentation, Beyrer emphasized the need to focus on strategies to help key populations who make up the bulk of new HIV diagnoses.

Beyrer cited data from the ATN 110 study, which examined PrEP use among young trans women and men who have sex with men. Researchers measured PrEP adherence through blood levels over a 12-month period and found that black participants were less successful in maintaining protective levels of the drug – which would require at least four doses per week. Further research is needed to determine how PrEP can be a more effective intervention for young black men who have sex with men.

The same study also found that 17% of participants had been expelled from their homes due to their sexual orientation or gender identity. During the Q&A, Beyrer emphasized that stigma around sexual orientation is also a problem in many countries where HIV is endemic – only a handful of African countries have decriminalized homosexuality and nine still carry the death penalty, which discourages people from seeking care.

Beyrer explained that, compared to women in the general population, female sex workers have an elevated risk for HIV, and that studies – including those by fellow Summit presenter Kate Shannon – have shown that decriminalization of sex work is one of the most effective ways to reduce new HIV infections. Beyrer provided examples of the negative impact that criminalization has on sex workers’ safety, including the fact that, in some jurisdictions, carrying condoms is used as evidence to charge someone with solicitation.

Beyrer also highlighted the challenges faced by trans women. Based on data from the only 15 countries reporting on trans populations, trans women are 30-50 times more likely to have HIV. The trans community would benefit from being able to access legally-appropriate identity documents and more research is needed on the interactions between PrEP and hormone replacement therapy.

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