When taken consistently and correctly, the co-formulation of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) (initially manufactured by Gilead as Truvada®) was shown to help reduce the risk of HIV infection through sexual contact by more than 90 per-cent. This strategy of using antiretrovirals for HIV prevention in uninfected people is called Pre-Exposure Prophylaxis – or PrEP for short. Despite the game-changing nature of PrEP, global uptake has been slow, with implementation in Asia and the Pacific piecemeal and fragmented. Regulatory, political, and financial barriers hinder access to the drug that many at-risk individuals could stand to benefit from

For this PrEP MAP article, we interviewed Dr Heather-Marie Schmidt, the new UNAIDS and WHO advisor who is working to advance the implementation of PrEP in the Asia-Pacific region. Heather-Marie is passionate about improving the HIV response across Asia-Pacific, including making PrEP available to those that need it.  Heather-Marie was the Senior Programmes Officer at APCOM. Dr. Heather-Marie Schmidt also led aspects of the design and implementation of the EPIC-NSW study in Australia. At that time, EPIC-NSW was the world’s largest PrEP trial – rapidly scaling up to provide PrEP services to almost 10,000 people at high risk of HIV.

Philips PrEP MAP (PM): Thank you so much for letting us poke your brains a little about PrEP implementation in the region. I’m excited to hear your thoughts!

Dr Heather-Marie Schmidt (HM): Thank you for having me!

PM: Dr Schmidt, what are 3-5 keys steps needed to plan for the introduction of PrEP and discuss what difficulties, if any, you could expect in bringing PrEP to scale, for some of the countries in the Asia-Pacific region?

HM: What a great question! Every country in our region is at a different stage with PrEP implementation, from not being available at all to being available as part of the national health insurance. Looking at the places that have been really successful with PrEP, I would say a few key priorities are:

• Political commitment. Having a strong Government commitment to implementing PrEP is important to its long-term success. The inclusion of PrEP in National Strategic Plans or clinical guidelines can be the first step.
• Community leadership. Mobilising the community around PrEP, advocating to stakeholders for PrEP access and generating demand is essential.
• Integrated, community-friendly delivery models. Having models to provide PrEP that are community-friendly, exist where the community need them and deliver a comprehensive package (including regular HIV and STI testing). Innovating in models of delivery can mean that PrEP is delivered in a low-cost way. Key population-led clinics, like the ones in Thailand and Vietnam, are one model that should be used more widely. It’s important that doctors, nurses, pharmacists and peers are well informed about PrEP.
• Monitoring and evaluation. It’s crucial that the implementation of PrEP, and the effect on the HIV response, is measured in a reliable way to show whether PrEP is successful and to justify Government and donor investment in PrEP programs.

But many other things need to happen. And many of these “priorities” need to occur at the same time. Bringing PrEP to scale in the Asia-Pacific is going to be a challenge.

PM: You mention inclusion of PrEP in National Strategic Plans or clinical guidelines as one of the first steps. Why is it so important to ensure PrEP is integrated into national health plans or clinical guidelines?

HM: PrEP is a crucial additional HIV prevention option. The science shows how effective PrEP is if it is taken as prescribed. And recent studies, including EPIC-NSW from Australia, show that if implemented at a population scale, PrEP helps cause dramatic drops in the numbers of new HIV infections. It’s quite an exciting tool, but it isn’t a silver bullet. PrEP needs to be implemented as part of a comprehensive HIV response, alongside HIV testing, treatment and other prevention interventions like condom promotion. So ensuring PrEP is integrated into national strategic plans is an important to start because it demonstrates the commitment of Government and key stakeholders to PrEP implementation. Making a public commitment can help donors and Governments fund PrEP in a country. It also helps advocates. Inclusion in national clinical guidelines helps to ensure that PrEP is provided to the people who need it safely and it begins to embed it into the national HIV response.

PM: How do you feel about people who are accessing PrEP informally, such as purchasing independently through an online website or sourcing it through friends or hookups?

HM: In most countries in our region, formal access options don't exist. But informal access isn't ideal. Informal access can make it difficult to ensure that you are taking a quality, safe drug that is going to protect you from HIV. And it can also make it more complicated to get accurate information and support from a doctor, nurse or peer, particularly if you’re worried about letting them know you’re on PrEP. So, if you are accessing PrEP informally, do your homework and use reputable methods to access PrEP.  Having a good clinic will make all the difference in making sure you’re safe and protected. Ask your friends or a community organization you’re comfortable with about community friendly clinics. I recommend talking to your doctor about PrEP, and making sure you’re having regular HIV and STI when you’re taking PrEP.

PM: What are some key takeaway messages about PrEP that you’d like to share with our audience?

HM: We need to remember that PrEP is just one HIV prevention option. It’s good to remember that PrEP works really well but only if you take it, so take PrEP as recommended by your doctor. Most people take it daily, but there are other patterns like ‘event-driven’ PrEP that will be right for some people. Taking PrEP can be really empowering HIV prevention option for people at substantial risk of HIV. But it isn’t right for everyone, and it does not prevent STIs or pregnancy.

Condoms are also a great, cheap HIV prevention option for many people (and they also help protect against STIs)!

PM: Lastly, as a final takeaway: What are some things PrEP MAP audience could be doing to support your work in advancing the implementation of PrEP?

HM: There are a lot of different things the PrEP MAP community could do to help, and they can be really small things (or big ones!):

• Raise awareness about PrEP within your communities
• Counter misinformation when you hear it and point to reliable information
• Advocate to your Governments and clinicians that PrEP is a crucial new tool in the fight against HIV and something they should help prioritise
• Support people to use the HIV prevention method that’s right for them.

Only if we all work together can we end the HIV epidemic!