Introduction by Croakey: The 25th International AIDS Conference is taking place this week in Munich, Germany, with the theme ‘putting people first’.
Conference organisers explain that this means thinking of solutions from the point of view of those most affected.
“For example, rather than thinking of hard-to-reach populations, we should think of hard-to-reach health services. HIV responses must be built for the individual, especially the most vulnerable,” they say.
Meanwhile, researchers from the Kirby Institute at UNSW Sydney have outlined reforms that would enable more equitable access to an important element of HIV prevention, Pre-exposure prophylaxis, or PrEP.
Their recommendations, which include measures to ensure cheaper, easier access to PrEP, are timely as the national Scope of Practice Review develops recommendations aimed at ensuring more equitable access to primary care.
Tyson Arapali and Benjamin R Bavinton write:
Australia is at a pivotal moment in our efforts to prevent people acquiring HIV. Pre-exposure prophylaxis, or PrEP, is changing the game in HIV prevention, yet we are not using it to its full potential and people are getting left behind.
In the 1980s, as the world grappled with the emerging HIV epidemic, Australia set a global standard for compassionate and effective HIV prevention.
We decriminalised homosexuality and sex work (in some states and territories), launched programs to distribute clean injecting equipment, invested in research and disease surveillance, and crucially, partnered with and empowered the communities most affected by HIV.
These approaches saved thousands of lives and made us world leaders in HIV prevention.
Here’s how we can ensure we stay ahead of HIV.
What is PrEP?
PrEP is a pill that, if taken correctly, is highly effective at preventing HIV. It can be used daily, or around the time of sex (known as ‘PrEP on-demand’ or ‘event-driven PrEP’).
Since 2018, about 75,000 Australians have used PrEP, which has been crucial in driving down HIV cases. In some inner city areas HIV cases have fallen by 88 percent.
But if we continue as we are, we are not going to eliminate the transmission of HIV, because not everyone who could benefit from PrEP can get it.
So, what’s holding us back?
Besides getting the word out and helping people realise PrEP is for them, it’s a mix of cost and healthcare system capacity.
It is particularly hard for people based outside of major city centres, women at higher risk, and Medicare-ineligible migrants.
Researchers from the Kirby Institute – an infectious disease research institute based at UNSW Sydney – have published a report containing three recommendations that could turn this around. These recommendations build on those made by the National HIV Taskforce late last year.
1. PrEP needs to be cheaper
First up, let’s talk about making PrEP more affordable. Despite subsidies, users pay nearly $100 per quarter, plus GP fees. Those ineligible for Medicare face even higher costs.
Compare that to countries like the UK, Germany, and Portugal, where PrEP is free. It’s no wonder that one in four people who want to take PrEP say they can’t afford it, and one in seven former PrEP users had to stop because of the cost.
Publicly funded sexual health clinics can reduce the cost to access PrEP; however, they aren’t located everywhere, and only have enough resources to see those most in need. And while the Government’s recent support for Medicare-ineligible individuals to access PrEP is a step forward, more can be done.
Even without free PrEP, there are other ways to bring down costs.
We could reduce the number of required doctor visits to one or two times a year, include PrEP in the new 60-day prescriptions program (allowing people to pay for 30 days of medications and receive double that), or promote non-daily dosing for those who are less sexually active.
The cost of preventing HIV is much cheaper than the cost of managing it.
2. Make PrEP easier to access
Next, we could think creatively about who can prescribe and supply PrEP.
Right now, accessing PrEP requires a doctor’s visit, creating bottlenecks. But many of these appointments are routine.
Internationally, some countries are shifting some or all PrEP appointment tasks – screening, counselling, sample collection, prescription writing – to other healthcare workers. This frees up doctors’ time and gives people more choice of where they can access PrEP.
NSW is in the process of allowing registered nurses in sexual health clinics to provide PrEP without a doctor’s prescription, allowing immediate access to PrEP and freeing up doctors for complex cases. This model could be expanded nationwide.
Pharmacies present another avenue for expanding PrEP access. In the USA, pharmacies have played a particularly critical part in helping people start PrEP before linking up with doctors for ongoing care. Trials in NSW, Victoria, and Queensland are currently exploring the impact of pharmacists being able to provide a few prescription-only medicines. While these trials don’t include PrEP, it could be added in the future.
Community-led sexual health clinics provide stigma-free environments ideal for PrEP distribution. They are available in numerous places around Australia, yet not all of them have doctors on site. This means would-be PrEP users need to go elsewhere.
Thailand found a solution by having highly trained peer workers collaborate remotely with doctors to provide PrEP to their patients. This highly successful approach has allowed 80 percent of people to access PrEP this way.
While the Thai model might not be possible in Australia, allowing nurses or pharmacists to work with these community-led services to provide PrEP could also be a solution.
3. Embrace new technologies
Lastly, we need to embrace new technologies. Telehealth – providing healthcare via phone call and video consultations – was the hero of the COVID-19 pandemic.
The Government’s decision to permanently subsidise sexual and reproductive telehealth appointments is great news – particularly for people living in regional areas, those who can’t get in to see a doctor in person, and those who don’t feel comfortable talking to their regular doctor about PrEP. Cost will still be a barrier for some, a gap which public sexual telehealth clinics might be able to fill.
Even though people can access PrEP through telehealth, they still need to go to a pathology collection centre for their blood tests, urine sample, and swabs. We could implement mail-order self-collected sample kits for lab tests, making it easier for people to access care from home.
HIV self-tests are available throughout Australia and are free to order, though lab tests are required for PrEP due to greater accuracy.
Where to next?
Of course, implementing these strategies will require collaboration across sectors. We’ll need healthcare workers, government, community members, and researchers all working together.
And we’ll need to recognise that what works in one part of Australia might not work in another – flexibility is key.
Australia has a proud history of leading the way in HIV prevention. Thanks to PrEP, in conjunction with effective testing and treatment initiatives, we can stop people acquiring HIV.
It’s an ambitious goal, but with a commitment to fair access for all, it’s within our reach. Let’s step up our PrEP game and continue to show the world what Australia can do.
Author details
Tyson Arapali is a Project Officer based at the Kirby Institute, UNSW Sydney. His work focuses on the determinants of PrEP use and how they can inform the development of innovative programs to increase PrEP uptake and retention.
Dr Benjamin Bavinton has worked in HIV prevention and research for 20 years in Australia and internationally. He is a Senior Research Fellow and Group Leader at the Kirby Institute, UNSW Sydney, focusing on HIV prevention among men who have sex with men and trans women in Australia and the Asia-Pacific. He has received honoraria, travel and unrestricted research grants from ViiV Healthcare, Gilead Sciences, and Virology Education.
• Croakey will publish more on the 25th International AIDS Conference in the forthcoming ICYMI column.
See Croakey’s archive of articles on HIV/AIDS
