The HIV Pre-exposure Prophylaxis (PrEP) prevention strategy may have proven effective in trials around the world, but does this mean PrEP will be effective in diverse, real-world settings, including in developing countries?

According to Burnet Institute Associate Professor Mark Stoové, it is vital we understand the local social, structural and political context of HIV risk and prevention to assess whether PrEP is feasible, and more importantly, whether it will be effective as part of a local HIV prevention strategy.

Associate Professor Stoové, the Head of the HIV/STI Research Group in Burnet’s Centre for Population Health, recently travelled to Myanmar to help implement a PrEP preparedness study.

He helped train and mentor field workers to survey more than 500 men who have sex with men (MSM) in Mandalay and Yangon to find out their understanding and awareness of PrEP and also explore potential barriers that individuals might experience in accessing PrEP.

The survey also addressed the attitude of MSM to PrEP to help understand how acceptable it would be for people who are HIV-negative but at high risk of infection to take HIV treatment medications to reduce their risk of acquiring HIV.

“There’s no point doing trials any more, because we know that PrEP works,” Associate Professor Stoové said.

“What we now need to do is more of these preparedness studies to really understand what implementation issues are specific to countries, to risk populations and environments.

“We need to understand the barriers to its implementation in the local cultural or health systems context, and to start, you need to engage the at-risk population about what they think about PrEP.

“This will be the first data of its type collected in a country that’s evolving very quickly, not only politically and socially, but also in relation to HIV prevention.”

Associate Professor Stoové said that while many people in at-risk populations do their own ‘informal’ PrEP through access to drugs via the Internet, effective management and support is vital.

“To go on PrEP, people need a health assessment, well functioning kidneys and livers because there are side effects around the use of these drugs,” he said.

“They also need to test for HIV regularly. If they seroconvert, people need to know that the drug they’re continuing to take may not be preventing them from being infected.

“They also need to be reassessed in relation to receiving appropriate HIV medications for their health, which may be different from the PrEP drugs they were taking for prevention.”

Associate Professor Stoové believes the considerations of the role of PrEP within a comprehensive HIV prevention strategy needs engagement from the highest levels of government and also must respond to local needs.

Myanmar is no exception over the medium to long term. However, currently many people living with HIV in Myanmar are still unable to access anti retroviral therapy (ART) to mitigate the health impacts of HIV.

Utilising anti retroviral drugs (ARV) in a resource poor setting to provide PrEP to HIV negative individuals must be carefully considered.

“While we need to turn off the tap of new infections, and PrEP is a proven intervention to add to this prevention toolbox, we need to continue to push for access to ARV for all the people living with HIV”.

The strategic use of ARVs for both treatment of infection and prevention of transmissions will require balance with strong policy support and commitment based on priority needs for prevention.

“What we’re trying to emphasise in this work is preparation for what the HIV prevention landscape might look like in five or ten years’ time,” Associate Professor Stoové said.

“In combination with a whole range of medium to long-term prevention strategies, I certainly think PrEP has a place in developing countries.”