HIV prevention in Europe today: Sheena McCormack
Could you tell us a little about your background and how you came to be working on HIV?
After qualifying as a doctor in 1982 and three years of further general medical training, I did some respiratory and chest work in Devon and London, followed by locum work in venereology in London. Before working in London, I’d never actually seen a patient with HIV or AIDS. In west London, however, the venereology clinic was full of people with HIV. These patients had all the associated complications, including pneumocystis carinii, which meant my respiratory skills and my general medicine skills were actually very relevant – something I hadn’t anticipated. Eventually this became a permanent job and I went on to become a consultant. It was an extraordinary time. You never forget the lovely people you looked after. When treatment became available, it was hard to believe that it would work or last.
So you’ve seen the field progress from having no treatment to effective treatment; what role do you envisage for prevention?
I actually went into prevention research in 1994, before cART became available, to do an early phase vaccine trial. At that stage, prevention was really important because there simply was no treatment. Then, as treatment gradually became effective, prevention became a little less important in many people’s eyes. But I never stopped realizing that it was going to be critically important because it’s like a tap going into a sink with a plug-hole. In the early days, the people with new infections were coming into the sink, dying and leaving the sink. But as treatment got better, the plug hole started to close and the sink kept filling up. All you can do now is turn the tap off, so we’re always going to need prevention.
What do you understand by prevention in HIV?
Well, you’re never going to get away from the ABC: Abstention, Be faithful, use a Condom. These work for the majority of people at any one time, but, at any one time, there’s also a population who can’t manage to use condoms consistently and who move from partner to partner. For that group we need something more. Of course this also depends on your epidemic setting. For example, in Northern KwaZulu-Natal in South Africa, young women of around 30 have a 50% chance of having HIV. Here, abstinence and being faithful isn’t enough; we’d have no chance of controlling the epidemic other than by using a vaccine, as well as aggressive testing and treatment and PrEP, as it affects the whole population. On the other hand, in western Europe, for example in Amsterdam or London, it’s different because we have very specific groups with HIV, for example gay men who understand health promotion messages. And of course, the majority of gay men will use a condom or be faithful, but for those who can’t, we recognize that we need to do something more and that’s where PrEP sits perfectly. We wouldn’t need a vaccine here; I think testing and treatment in combination with PrEP would do the trick and make that sink less full. On the other hand, for our sub-Saharan African populations in Europe it’s a little more tricky because access to testing and the barrier to testing hampers efforts to use test and treat and PrEP. In this population, we’ve got much more to do at a societal level to make access easier and to overcome the stigma issue.
Then, in eastern European countries, where HIV is associated with injecting drug use, quite draconian measures have exacerbated the situation and made it difficult for people to come forward and be tested and take their treatment. Nonetheless, in all these countries there are champions and ambassadors working at the community level. And while engaging the community is easy in, for example, the gay community where they’re very well networked through social media and word of mouth, it’s much harder, but certainly not impossible, to engage these other communities. So this is what needs to happen in these settings, but it’s slightly more complex than simply delivering PrEP or a vaccine.
There are obstacles to PrEP too though in countries such as the UK and Netherlands, aren’t there?
Yes, obviously the cost is the big obstacle. All governments across Europe spend less on prevention than on treatment, and the public health budget is inevitably small compared to the care budget. We need to acknowledge that we need to put a bit more into public health and prevention, particularly for young people. And then I think in the Netherlands there are some particular obstacles due to the way the public health is funded, whereby I believe it’s not free for everybody to have an HIV test. This is particularly a problem for young people, who may not be able to afford the co-payments associated with prevention. It’s important that governments and policy makers acknowledge that and are prepared to bear the extra costs (including those associated with additional screening for STIs). After all, they should save that money off the treatment budget for HIV because, unlike PrEP which you take for a period in your life when you’re at risk, HIV treatment is for life. So it’s a gain in the longer term.
In the UK, HIV and STI testing is free and STI treatment is free and provided through specialized walk-in clinics. Particularly in London, these clinics are very accessible and could easily be employed for PrEP distribution and monitoring of PrEP use. Unfortunately, PrEP is not yet available on the national health service (NHS), because of the cost of the drug. It’s very frustrating, but we are hoping that the NHS will make a decision soon about whether to fund a national PrEP programme.
Do you anticipate any problems with PrEP in terms of resistance or adherence?
I don’t think there will be a problem with resistance in either the individual or the population. I actually think people struggling to adhere to treatment is a far greater source of resistant virus circulating in the population than PrEP will be. So, while I think that we can’t dismiss it, we shouldn’t let it get in our way. In terms of safety, at least in young people, I do question whether we need to do any safety bloods at all unless they’re on other drugs or have other conditions. The component drugs in Truvada are very, very safe and we’ve been using it for years in people who have HIV and who take it with another drug.
In terms of adherence, the key message is that you only have to adhere during periods of your life when you’re at risk. So provided people take the drug when they’re at risk, it should be fine. The problem is that you will still have some people who are at risk, but who struggle to acknowledge that and who therefore won’t be taking the tablets at all. All of the infections we saw in PROUD, occurred in people whose story implied they were not taking PrEP at the time they were at risk. In countries where people have struggled to adhere to PrEP, it’s been in settings where there’s a large stigma associated either with HIV or with being gay, and that’s fundamentally the problem. Anywhere where people struggle to adhere to treatment for HIV they are likely to struggle to adhere to PrEP, because it gives them an HIV label that they don’t want.
So, finally, a really big part of HIV prevention has to be about strengthening civil society and the community and working to tackle stigma. We can’t do that from only the healthcare provider point of view. I really admire what cities like Amsterdam and Paris are doing, bringing together all the resources to tackle a common problem. It’s very important and effective to have political support for such initiatives. We need more examples of that and for them to spread, because if people don’t see HIV as a threat, they won’t see PrEP as a problem.