PrEP in Scotland Some dropouts and some HIV infections (!!!!!)

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One Year of PrEP in Scotland: Some dropouts and some HIV infections!

Some HIV Infections!

Editor's note / translator / and everything from Seropositivo.Org

What led me to translate this text was exactly what caught my attention in the title in English:

First year of PrEP in Scotland: more users than expected, few dropouts, few HIV infections

"Some HIV infections"

This title, in my opinion, is a disgrace !!!!

Implicit for me is something like this:

You idiots take the pills to treat HIV while you do not have HIV to see if they do not get HIV. And, if you get HIV (something is missing here) ... Well, those of you who, in the meantime, are already taking antiretroviral drugs like PrEP, well, for you, "it does not change anything", because you are already taking antiretrovirals ! It's just changing the acronyms, continuing life filling our most coveted coffers! In all of this, for me, only one ops was missing!

The Faces That Sell!

I have an article to be translated, it is old and time does not help, but now it has become urgent, because its title in English, roughly is something like:

PrEP as BRIDGE for HAART !!!!!!!

A bridge to the future! Not that (...) the PMDB (Is not this the party known as the old prostitute?) Forgive me, sex workers already retired, I did not mean to offend .... And, I know, you know that I respect you more than they

If PrEP is to avoid HIV infection what kind of study is this? What is the purpose of all this?

Placing non-HIV-positive people on ART with another logo on the pretext of prevent HIV infection and, if caught, well, you are already, same, used to it (with the whole idea in itself) with the medication and, then, does not change anything!

They cover me the "text of the bridge". They cover me to death!

The recent report on the first year of the implementation of pre-exposure prophylaxis (PrEP) through the National Health Service (NHS) in Scotland concludes: "The first year has been a resounding success in terms of establishing a new national service - the first of this type in the UK and one of the first in the world. "

In total, 1872 people received Prescription PrEP in Scotland during the first year of the program. If the same proportion of the population of England had been prescribed PrEP, this would represent more than 19.000 people.

Between one and four were infected with HIV after being prescribed PrEP. The uncertainty is about the exact date of HIV infection; what is known is that none of the people involved had pre-drug levels of blood in the time of infection (sic).

Most Only Use PrEP Temporarily - It's The Same Condom Problem

It is not the method, the condom, that needs to be changed. It is Consciousness. I was missing one, as a sad example

Since most people only took PrEP for a few months before July of 2018, when the latest data from the report was collected, accurate reduction in HIV incidence is difficult to calculate, but the data suggest that people who prescribed PrEP were up to 75% less likely to become infected with HIVas if such a number were good !!!! - than those who do not.

The Health Protection Scotland report says this has been achieved despite several factors that may have acted as barriers:

  • a mere four-month gap between the Scottish Council Medicines PrEP approval and the start of their NHS rollout
  • the novelty of PrEP and the training of associate staff needs a higher-than-expected demand, including a high proportion of people who have never attended sexual health clinics,
  • no additional public money allocated for this.

As you can see below, there is a logistical / structural cost with IT investments that are not low

The introduction of PrEP required administrative and structural changes, such as new IT and coding systems introduced in the sexual health surveillance system, and mechanisms for cost reimbursement of patients attending clinics outside their area of ​​residence, including England. New patient education materials also had to be developed.

The success of the program. Health Protection Scotland says, "exceeded expectations" and was partly due to the decision to involve all stakeholders in multidisciplinary teams throughout the process - including third sector organizations, community activists, service providers, politicians, NHS administrators and external experts including doctors and advocates who at the time were supporting generic PrEP users in England.

PrEP users, how were they chosen for this study?

O NHS Scotland, have defined four eligibility criteria for risk behavior for PrEP. Of the 1872 people who prescribed PrEP in the first year, the eligibility criteria was not recorded in 28% of cases.

Of the remainder, 78% were gay and bisexual who had unprotected anal sex during the past year with two or more partners.

Meanwhile, other 18% of users fell on the criterion of having had a sexually transmitted bacterial infection in the last year; 2% had a seropositive partner with undetectable viral load; and 1% were judged by doctors as "at equivalent risk"!

Catch All PrEP to Risk

The so-called "catch-all" category designed to allow doctors to prescribe PrEP to people who could not be at risk (an example might be someone in an abusive relationship who suspected their partner might have HIV).

It may be comforting that a relatively small number of people (274, or 11% with PrEP as a reason for attendance) went to a clinic for PrEP, but was found ineligible, showing that doctors were not prescribing. "

On the other hand, practically all people who prescribe PrEP were gay or bisexual men, with only 14 people identifying themselves as women and nine as heterosexual men - among them only 1,2% of PrEP users or less than half the proportion of non-gay participants. in the IMPACT test version in English. The Scottish report recognizes that "more needs to be done to raise awareness of PrEP among women, transgender and heterosexual men," and promises to conduct research on how best to meet their needs.

PrEP Users in Scotland Are in the Same Age Age of Visitors This Blog

Most people who prescribed PrEP (56%) had between 20 and 35 years, but one in seven was over 50 years old, and this age group was particularly well represented among the first adopters. Seventy (3,7%) PrEP users were less than 20 years old.

There was immediate interest in PrEP as it was offered in July of 2017, the peak month of new revenue being in October, with 211 new users of PrEP.

PrEP prescriptions in stepwise reduction

After that, new prescriptions decreased to about 125 per month until June of 2018, although the month with the highest number of prescriptions total been in May of 218, with 519. Scotland offered patients the option of daily or event-based PrEP; 74% chose the daily PrEP and 17% of the PrEP based on events, with the other 9% shifting from one to the other during the year (a bit more daily for event-based than the other).

A significant and unexpected finding was that a high proportion of PrEP searchers were people who were attending a sexual health clinic for the first time (19%) or did not attend for at least two years (11%).

Many of the older homosexuals were in this category.

Only 2% of patients with PrEP prescribed during the year (45 people) were reported as having stopped. This obviously does not reflect the true value, since most people who stopped would simply not have returned, rather than tell their clinic.

If each person prescribed PrEP during the year had taken PrEP daily and filled their prescriptions every month, the number of repeated prescriptions would have been at least double 4432 actually seen, but adherence would never be realistically so high.

HIV testing and results

As expected, the influx of people presenting to PrEP resulted in a considerable increase in HIV and STD testing in sexual health clinics.

HIV testing was on a rising trajectory - in gay and bisexual men who arrive at IST clinics, the number of tests per quarter increased from 1920 in the middle of 2014 to 3250 at the time PrEP began in July of 2017.

Further increased to 4150 tests in June of 2018.

In the patients who received PrEP prescription, the increase was much more pronounced. Looking back, about 250 of these 1872 people performed an HIV test in the second quarter of 2014; 750 performed a test in the quarter started by PrEP (July to September of 2017); and 1450 - 35% of all gay and bisexual men testing at STD clinics - in the quarter that included June of 2018.

The cumulative number of HIV testing among PrEP users was one of the additional burdens that clinics had to endure.

Diagnosis of HIV Infection Increases in All Populations

Despite the increased number of tests, HIV diagnoses actually declined among gay men in the first year PrEP was available.

HIV diagnosis at all sites (not just STI clinics) decreased in male and female bisexuals of 91 in the year prior to PrEP for 76 in the first year. In contrast, the HIV diagnosis in all populations increased from 189 to 215 in the same period.

Not PrEP

The decrease in HIV diagnoses among homosexuals is almost certainly not due to PrEP, or not yet. By the middle of 2016, HIV diagnoses in MSM in STI clinics were around 80 per year. During the following year - to that before the PrEP became widely available - they fell sharply to 47 and were 43 in the year after the start of PrEP. Cases of recent HIV infection - acquired less than six months prior to testing - dropped similarly from about 30 per year before July from 2016 to 17 in 2016-7 and 19 in 2017-8.

This decrease seems to mirror those observed in England at the same time and was similarly attributed to increases in HIV testing and to the proportion of people on antiretroviral therapy who are suppressed by viruses.

IST tests and results

The number of IST tests more or less mirrored in HIV testing increased at the same highest rate in people who took PrEP or who would continue to take PrEP.

And the diagnoses of gonorrhea increased between mid 2014 and mid 2018, as they have elsewhere, from about 170 a quarter in June from 2014 to more than 300 from a quarter at the beginning of PrEP in July of 2017 and about 400 in the last quarter of 2017.

The increases were much higher in the men who took PrEP!

For the obvious reason! PrEP may even prevent some HIV infections, but it opens up wings, with Chiquinha Gonzaga's pardon for STDs, and with an epidemic of gonorrhea almost without a cure spreading, it makes a lot of sense to find ways to not use a condom!

Even among those who were "taken into account the possibility of using PrEP

Or, they would adopt it, with 85 per quarter at the beginning of PrEP available for 160 per quarter in the last quarter of 2017.

This is equivalent to using the credit card without salary !!!

More Tests are the Cause. It's ... You know that Shadow of the Sieve?

This seems a large increase in gonorrhea in PrEP men, but it is almost entirely due to more tests. THE proportion of men who underwent IST tests diagnosed with gonorrhea were 8,05% during July from 2016 to June of 2017 in men who never used PrEP and 10,9% in men who started using PrEP the following year. The following year, the rate was 7,25% in men who did not use PrEP and 11,9% in men taking PrEP. The difference between PrEP users and nonusers is statistically significant, but year-to-year changes are not.

As the report puts it: "[There were] more 318 diagnoses [of gonorrhea] in men with prescribed PrEP compared to an additional eight in non-prescribed PrEP men ... these observations reflect multiple visits to sexual health clinics (including STI testing) .

Implementation issues and possible impact on public health

The first year of PrEP was not achieved without difficulties, expected and unexpected. The beginning of July of 2017 coincided with the human papillomavirus (HPV) vaccine being introduced to gays with less than 45 years, so that clinics had a double burden of new prescriptions.

This has led many patients to need much longer consultations than usual. Some clinics solved this problem by introducing pre-interview interviews by nurses who collected behavioral data, with doctors called only to give test results, prescribe PrEP if necessary, and explain dosage and adherence.

At first, disproportionate concerns among some employees about the side effects of PrEP and drug interactions persisted despite the training, but these decreased as the team gained more experience with PrEP users and with the results of the interpretation labs.

Some physicians struggled with patients who had complex eligibility problems, but these were resolved by physicians creating "professional support systems for couples," such as so-called virtual clinics.

On the other hand, fewer people than expected traveled from England or elsewhere to get the Scottish PrEP. *

When PrEP started, only the brand Truvada was available at a cost of £ 355 for 30 days, but Commissioners decided to buy generic drugs at one-tenth the price.

These became available in October, although "this was subject to legal challenge." Another cost-effectiveness measure adopted was the release of PrEP to patients on the day of their initial evaluation, as in England.

The report says that "occasional" patients ended up having acute HIV that day and had to be withdrawn, but they do not say how many.

Difficult to Define if the Result is Due to PrEP

Is still difficult to say if PrEP produced any further reduction in HIV infections at the population level. There was a decrease in the proportion of positive HIV test takers in July from 2017 - June to 2018 compared to previous 12 months, from 0,4% of all testers to 0,3%, but no decrease in people who had recently acquired HIV. The "between one to four" people who took HIV even though they were prescribed PrEP would indicate an overall annual incidence of HIV among all PrEP takers from 0,1% to 0,4%, indicating group-level efficacy of up to 75% but PrEP is still too new for any population to be observable.

* Eligibility - What is the problem in the eligibility of the condom supply?

Age and size. Once these "variables" are set ...

* Scottish PrEP .... I do not see equivalent difficulty in the case of condoms ....

£ 355 .... Would the condom cost £ 1.00 (almost $ 5.00)?

Population Level! The condom, which I so much question I did not use has minimized impact after population impact. What is the point in implementing PrEP, when establishing condom use is much cheaper and is fudamentado exactly what I did not have?

Education regarding sexual and reproductive health.

I was such an idiot that I considered DST a kind of war trophy (...)!

Translated By Cláudio souza do Original in First year of PrEP in Scotland: more users than expected, few dropouts, few HIV infections by Gus Cairns Originally posted in 02 April 2019


Health Protection Scotland. Implementation of HIV PrEP in Scotland: First Report of the Year. Watch for full report, abstracts and infographic.

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