Hi from Switzerland!
The journey to Switzerland to report for INPUD had been a tiring one. After presenting a session in Glasgow at the National Conference on Injecting Drug Use, it was straight back to London and out the door for a flight to Geneva airport. I had been asked by INPUD to attend a consultation staged by the World Health Organisation, to report on a topic I have to admit to being unfamiliar with – ‘PrEP’ – or Pre Exposure Prophylaxis.
My first thoughts were of the HIV vaccine. Many of us may remember hearing of the recent breakthrough in the HIV vaccine trials, news which appeared out of the blue after many years of research of seeming dead ends and disappointments. However, while I was in the right ball park thinking vaccines, this was a very diferent game. PrEP you could say was more like PEP’s (Post Exposure Prophylaxis) newest cousin.
Instead of PEP – and its use as the short sharp shock of HIV treatments (anti retrovirals) for, most commonly, health professionals exposed to the virus via occupational related incidents such as needle stick injuries etc, PrEP is about taking things much further.
It is an experimental HIV prevention strategy that, if proven, would use anti retrovirals (ARVs) to reduce the risk of HIV infection in HIV negative people. Could PrEP, through the ingestion of a single drug (or combination) taken daily, reduce the chance of HIV infection – in HIV negative people? If found to be effective, how would such a prevention approach be rolled out? And to whom? In combination with what other prevention measures? And would HIV negative people even adhere to such a potentially uncomfortable drug regime with no immediately tangible benefit? And what about drug resistance – could we be making a rod for our own backs?
One of the potential advantages of PrEP is that those who are unable to negotiate condom use with their sex partners, would still be able to reduce their risk of infection. People who inject drugs may still be able to protect themselves despite being in higher risk environments such as without access to sterile needles and syringes.
There is however, a worrying lack of data, although current trials are well underway. These are looking at a range of transmission routes in diverse populations such as; Serodiscordant couples (one postive, the other negative); hetrosexual men and women in high prevalence areas; people who inject drugs; gay men and other men who have sex with men.
Yet there is an optimism about PrEP. Despite the fears and concerns of diverting potentially scarce resources away from positive people to negative ones when we still have not achieved the UNAIDS goals of universal access by a long shot, over 20,000 people are currently in PrEP trials, and the data will be emerging over the next few years. If, as hoped the results prove as encouraging as some believe, substantial preparation is needed to effectively scale up and implement such an intervention. In order to avoid unnecessary delays, additional research questions must be asked, and priorities decided upon.
Setting The Stage –
Scientist Kevin O’Reilly (Prevention in the Health Sector) has picked a fairytale setting for the meeting. An hour and a half from Geneva itself, the tiny town of Glion is picture perfect. A rickety little tram ascended up the mountainside from Montreux, taking me to Glion’s only hotel, sitting like a magnificent wedding cake, lodged firmly into the mountainside and overlooking the Swiss Riviera. After being given the key to my room I don’t mind admitting I launched into a mini boogaloo, before throwing myself on the big double bed, my eyes bulging at the view from my very own balcony! So this is how the other half live! After coming from the grey envelope of London, this was nothing short of breathtaking.
But there was no way this was any sort of a holiday; the huge array of complex issues involved in the emerging PrEP discussion was phenomenal, as I realised reading up on the materials I had been sent, en route to Glion this week. And after the first day of discussions, it was proving a very complex task with a massive amount of variables, and very little data to base decisions on.
It was great to meet up with my INPUD colleague Jason Farrell, who had trekked over from Amsterdam and members will be pleased to know he was both reflective and vocal during the ensuing consultation, raising the issues that related to our using community with clarity and emotion. Mixing the personal with the practical is often what is missing at meetings where so much is about data and health systems, and it was one of Jasons personal experiences that brought a touch of reality back into discussions. Which is, after all, why we are here. To ensure the discussions and hopes for PrEP, encompass the reality of peoples lives, in particular, for Jason and myself representing INPUD in relation to people who inject drugs. We want to ensure any guidelines created by WHO on PrEP, take user issues into account, particularly since 2,400 thai people who inject drugs (PUDs) are due to emerge from a trial in 2010, and being a government endorsed programme it is possible any rolling out of PrEP, may continue there. By WHO and UNAIDS collaborating on this issue and bringing together civil society, trialists, academics, investors, researchers, statisticians, and scientists to who PrEP is pertinent, discussion will focus on the research needed to conduct and prepare for implentation of PrEP, and what issues will have the highest priority?
Alas, it is now late and I am about to turn out the light and snuggle up in the wedding cakes puffball of a bed, to blog again tomorrow on the rest of todays discussion as we move past setting the scene and towards hearing more from the cast, to thinking about the strands involved in the story ahead.
Til tomorrow night, Bon soir!