Pre-Exposure Prophylaxis for HIV Infection as a Public Health Tool

The efficacy of pre-exposure prophylaxis, PrEP, with antiviral agents for prevention of HIV infection has been demonstrated in multiple randomized controlled trials and demonstration projects. These trials have studied prevention at the individual level. The effectiveness of PrEP as a public health intervention to reduce HIV incidence at community and population levels is being actively evaluated but is less well described. In reviewing the available data on PrEP as a public health intervention, three significant examples have demonstrated success, and all have been among communities of gay, bisexual and other men who have sex with men (MSM)

Monitoring HIV pre-exposure prophylaxis (PrEP) uptake in Australia: Issue #8, May 2023

HIV pre-exposure prophylaxis (PrEP) was listed on the Pharmaceutical Benefits Scheme (PBS) on 1 April 2018. The PBS subsidises the cost of PrEP for people eligible for Medicare in Australia. The cost to the patient for 30 pills as of May 2023 was $30.00 for general patients and$7.30 for concession card holders. This report uses data from every PBS-subsidised PrEP prescription that was dispensed in Australia between 1 April 2018 and 31 December 2022. The de-identified data incorporate unique codes for linking individuals. Variables include patient details (age, sex, postcode of residence, concession status), information about dispensing (date of dispensing, quantity dispensed), and prescriber details (postcode, specialty). Data are presented on the total number of people who have ever initiated PBS-subsidised PrEP, as well as the number of people dispensed PrEP within each quarter, and within the past 12 months. These data are disaggregated by age, and by state or territory of patient residence, and presented as population rates. This report also includes a section investigating the effect of COVID-19-related lockdowns on monthly dispensing data by jurisdiction

Cost-effectiveness of adult circumcision in a resource-rich setting for HIV prevention among men who have sex with men

Background.&nbsp; We examined the effects and cost‐effectiveness of 4 strategies of circumcision in a resource‐rich setting (Australia) in a population of men who have sex with men (MSM).Method.&nbsp; We created a dynamic mathematical transmission model and performed an economic analysis to estimate the costs, outcomes, and cost‐effectiveness of different strategies, compared with those of the status quo. Strategies included circumcision of all MSM at age 18 years, circumcision of all MSM aged 35&ndash;44 years, circumcision of all insertive MSM aged 18 years, and circumcision of all MSM aged 18 years . All costs are reported in US dollars, with a cost‐effectiveness threshold of 42,000 per quality‐adjusted life‐year.Results.  We find that 2%–5% of human immunodeficiency virus (HIV) infections would be averted per year, with initial costs ranging from 3.6 million to $95.1 million, depending on the strategy. The number of circumcisions needed to prevent 1 HIV infection would range from 118 through 338. Circumcision of predominately insertive MSM would save$21.7 million over 25 years with a $62.2 million investment. Strategies to circumcise 100% of all MSM and to circumcise MSM aged 35&ndash;44 years would be cost‐effective; the latter would require a smaller investment. The least cost‐effective approach is circumcision of young MSM close to their sexual debut. Results are very sensitive to assumptions about the cost of circumcision, the efficacy of circumcision, sexual preferences, and behavioral disinhibition.Conclusions.&nbsp; Circumcision of adult MSM may be cost‐effective in this resource‐rich setting. However, the intervention costs are high relative to the costs spent on other HIV prevention programs.<br /

Exploring anal self-examination as a means of screening for anal cancer in HIV positive men who have sex with men: a qualitative study

Background: Anal cancer is relatively common in HIV-positive men who have sex with men(MSM). However there are no clear guidelines on how to effectively screen for anal cancer. As earlier diagnosis of anal cancer is associated with increased survival, innovative ways such as utilizing anal self-examination to identify anal cancer should be explored. Method: Semi-structured interviews were conducted with 20 HIV-positive MSM from a range of ages (35 to 78 years). This study explored acceptability and barriers to implementing ASE as a method of anal cancer screening. Framework analysis was used to identify themes. Results: Seventeen out of 20 men had conducted an ASE before - six (35%) were for medical reasons, six (35%) for sexual reasons, three (18%) for both medical and sexual reasons, and two (12%) for cleaning purposes. Only 5 men were currently confident in detecting an abnormality. Whilst men were generally comfortable with the idea of utilizing ASE as a means for detecting anal cancer, potential barriers identified operated at three levels: attitudinal (discomfort with any anal examinations, anxiety about finding an abnormality, preference for health professional examination), knowledge (lack of awareness of anal cancer risk and ignorance of anal cancer symptoms) and practical (inadequate physical flexibility, importance of hygiene). Conclusion: ASE may be an acceptable means for anal cancer detection in HIV-positive MSM but training in detecting abnormalities is needed. The preference for health professional examination and inadequate physical flexibility may preclude its use for some men. Future trials to confirm its wider acceptability will be needed before undertaking an effectiveness trial for detecting anal cancer

Sustaining sexual and reproductive health through COVID-19 pandemic restrictions: qualitative interviews with Australian clinicians

Background. The sexual and reproductive health care of people with HIV and those at risk of HIV has largely been delivered face-to-face in Australia. These services adapted to the coronavirus disease 2019 (COVID-19) pandemic with a commitment to continued care despite major impacts on existing models and processes. Limited attention has been paid to understanding the perspectives of the sexual and reproductive health care workforce in the research on COVID-19 adaptations. Methods. Semi-structured interviews were conducted between June and September 2021 with 15 key informants representing a diverse range of service settings and professional roles in the Australian sexual and reproductive health sector. Inductive themes were generated through a process of reflexive thematic analysis, informed by our deductive interest in clinical adaptations. Results. The major adaptations were: triage (rapidly adapting service models to protect the most essential forms of care); teamwork (working together to overcome ongoing threats to service quality and staff wellbeing), and the intwined themes of telehealth and trust (remaining connected to marginalised communities through remote care). Despite impacts on care models and client relationships, there were sustained benefits from the scaleup of remote care, and attention to service safety, teamwork and communication. Conclusions. Attending to the experiences of those who worked at the frontline of the COVID-19 response provides essential insights to inform sustained, meaningful system reform over time. The coming years will provide important evidence of longer-term impacts of COVID-19 interruptions on both the users and providers of sexual and reproductive health services