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Letter To The Editor: The Role For Pre-Exposure Prophylaxis In The Fight Against AIDS

Jul 27, 2012

Letters to the Editor is a periodic KHN feature. We welcome all comments and will publish a selection. We will edit for space, and we require full names.

The letter below concerns KHN's interview with Michael Weinstein, the president of the AIDS Healthcare Foundation. As part of our coverage of the AIDS conference in Washington this week, we also interviewed Greg Millett, Lisa FitzpatrickPhill Wilson and Tiffany West.


HIV/AIDS is still an emergency. We've heard this week at the International AIDS Conference about the great strides in our response to the epidemic, but we¹ve also heard that we need to accelerate our responses across the board, employing all of the prevention options that have been proven to work in our bid to put the virus on the run.

Yes, we have a long way to go before we end the epidemic here in the U.S. and around the world. And scaling up HIV testing and linking people who are HIV-positive to treatment and care and people who are HIV-negative to an appropriate range of prevention options is the most important thing we can do to respond to the epidemic. For some people, the range of appropriate prevention options includes voluntary medical male circumcision (VMMC) and for some it includes pre-exposure prophylaxis (PrEP). VMMC and PrEP work. The evidence is clear -- and it is no distraction!

We know how to implement VMMC in African countries where it can have the highest impact. We're working to understand how best we can implement PrEP in communities here in the U.S. and around the world where it can have the most impact.

Daily oral PrEP using TDF/FTC is absolutely not a silver bullet. It provides partial protection and is not a replacement for other prevention strategies like the male and female condom. It will not be right for everyone. It requires adherence, a confirmed HIV-negative diagnosis and ongoing monitoring. Further, there are a number of questions remaining about how PrEP can be implemented in different communities and how it will best be used by those who need it most.

But the evidence that PrEP works when used correctly is incontrovertible, and it is important to look at the range of data from all of the clinical trials of PrEP, not just data from a single trial. The U.S. Food and Drug Administration (FDA) approval and the recent World Health Organization (WHO) guidance on PrEP was based on a rigorous review of data from four large scale clinical trials in different communities. Importantly, the Partners PrEP trial among 4,758 heterosexual couples in which on partner was HIV-positive and one was HIV-negative found that daily oral TDF/FTC reduced risk of HIV infection by 73 percent overall.

PrEP, like condoms, works when used consistently and correctly. Evidence from the iPrEx, Partners PrEP, TDF2 and FEM-PrEP trials show us that when trial participants took the drug as prescribed there was a high level of protection.

There are no magic bullets! PrEP, like any strategy, won't end the epidemic alone, and certainly not with the current, poor rates of HIV testing and linkages to care or even access to male and female condoms. The best-case scenario is one in which people are choosing from a menu of options throughout their lives.

We know that PrEP will never be the answer for everyone at risk of HIV infection, but it is an important new choice in a combination of prevention options that includes male and female condoms, behavior change, harm reduction, voluntary medical male circumcision, and early and consistent treatment for HIV-positive people. It is unethical not to provide.

A decade ago many skeptics believed we could never roll out HIV treatment to people in Africa and other parts of the developing world. Today, eight million people around the world are receiving HIV treatment. We can and must also provide access to PrEP for those who need it.

Mitchell Warren
Executive Director, AVAC: Global Advocacy for HIV Prevention
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