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

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

Some HIV Infections!

Editor's note / translator / and everything / Tor de Soropositivo.Org What led me to translate this text was exactly what caught my attention in the English title: First year of PrEP in Scotland: more users than expected, few dropouts , few HIV infections “Some HIV infections” This title, in my opinion, is nonsense !!!! Something like this is implied to me:
You idiots take the drugs to treat HIV while you don't have HIV, to see if you don't get HIV. And, if you contract HIV (something is missing here)… .. Well, those of you who, in the meantime, are already taking antiretrovirals like PrEP, well, for you, “it doesn't change anything”, because you are already taking antiretrovirals ! Just change the acronyms, continue life by filling our crammed coffers! In all of this, for me, there was only one “ops” 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 !!!!!!!

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A bridge to the future! Not that (…) of the PMDB (isn't this the party known as the old prostitute?) Forgive me, sex workers already retired, I didn't mean to offend…. And, I know, you know that I respect you more than they do
If PrEP is to prevent HIV infection, what kind of study is this? What is the purpose of all this? Putting people without HIV 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, yes, nothing changes!

I cover the “bridge text”. Cover me to death!

The recent report on the first year of 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 United Kingdom and one of the first worldwide. ”In total, 1872 people received a prescription for PrEP in Scotland during the first year of the program. If the same proportion of England's population had been prescribed PrEP, it would have represented 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 preventive drug levels in their blood at the time of infection (sic).

Most Only Use PrEP Temporarily - Same Problem With Condom

It is not the method, condom, that needs to be changed. It is Consciousness. I lacked one, as a sad example Since most people only took PrEP for a few months before July 2018, when the latest report data was collected, it is difficult to calculate an accurate reduction in HIV incidence, but the data suggest that people who prescribed PrEP were up to 75% less likely to become infected with HIV - as if such a number were good !!!! - than those who do not receive it. The Health Protection Scotland report says that this has been achieved despite several factors that may have acted as barriers:
  • a mere four-month difference between the Scottish Medicines Council PrEP approval and the start of your NHS rollout
  • the newness of PrEP and the training of associated staff needs a greater than expected demand, including a high proportion of people who have never attended sexual health clinics,
  • no additional public money allocated for this.

As seen 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 reimbursing costs for 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, "it exceeded expectations" and was partly due to the decision to involve everyone interested in multidisciplinary teams throughout the process - including third sector organizations, community activists, service providers, politicians, NHS administrators and outside experts, including doctors, and argues that they were supporting generic PrEP users in England at the time.
PrEP users, how were they chosen for this study?
O NHS Scotland, defined four risk behavior eligibility criteria for PrEP. Of the 1872 people who prescribed PrEP in the first year, the eligibility criterion 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, another 18% of users fell under the criterion of having had a sexually transmitted bacterial infection in the past year; 2% had a seropositive partner with an 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 could be someone in an abusive relationship who suspected that their partner might have HIV). It can be comforting that a relatively small number of people (274, or 11% with PrEP as a reason for attendance) went to a clinic in search of PrEP, but were found ineligible, showing that doctors were not prescribing “. On the other hand, practically all people prescribed 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 proportion of non-gay participants. in the English version of IMPACT. The Scottish report recognizes that "more needs to be done to raise awareness of PrEP among women, trans people and heterosexual men" and promises to conduct research on the best way to meet their needs.

PrEP users in Scotland are in the same age group as visitors to this blog

Most of the people who prescribed PrEP (56%) were between 20 and 35 years old, but one in seven was over 50, and this age group was particularly well represented among early adopters. Seventy (3,7%) PrEP users were under 20 years old. There was immediate interest in PrEP as soon as it was offered in July 2017, being the peak month for new revenues in October, with 211 new PrEP users.

PrEP Prescriptions in Gradual Reduction

Thereafter, new prescriptions decreased to around 125 per month until June 2018, although the month with the highest number of prescriptions total May 218, with 519. Scotland offered patients the option of daily or event-based PrEP; 74% chose daily PrEP and 17% chose event-based PrEP, with the other 9% switching from one to the other during the year (slightly more daily to event-based than the other way around). A significant and unexpected finding was that a high proportion of PrEP seekers were people who were attending a sexual health clinic for the first time (19%) or who did not attend for at least two years (11%). Many of the older homosexuals were in that category. Only 2% of patients with PrEP prescribed during the year (45 people) were reported to have stopped. This, of course, does not reflect the true value, as most people who stopped simply would not have returned, instead of telling 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 twice the 4432 actually seen, but adherence would never be realistically so high.
HIV testing and results
As expected, the influx of people presenting for PrEP has resulted in a considerable increase in HIV and STD testing at sexual health clinics. HIV testing was on an upward trend - in gay and bisexual men arriving at STI clinics, the number of tests per quarter increased from 1920 in mid-2014 to 3250 at the time PrEP started in July 2017.

Further increased to 4150 tests in June of 2018.

In patients who received a prescription for PrEP, the increase was much more pronounced. Looking back, about 250 of those 1872 people took an HIV test in the second quarter of 2014; 750 performed a test in the quarter started by PrEP (July to September 2017); and 1450 - 35% of all gay and bisexual men testing at STD clinics - in the quarter that included June 2018. The cumulative number of HIV tests among PrEP users was one of the additional burdens that clinics had to endure.
Diagnosis of HIV Infection Increased in All Populations
Despite the increase in the number of tests, HIV diagnoses have actually decreased among gay men in the first year that PrEP was available. HIV diagnosis at all sites (not just STI clinics) decreased in gay and bisexual men from 91 in the year prior to PrEP to 76 in the first year. In contrast, the diagnosis of HIV in all populations increased from 189 to 215 in the same period.
Not due to PrEP
The decrease in HIV diagnoses among homosexuals is almost certainly not due to PrEP, or not yet. As of mid-2016, HIV diagnoses in MSM in STI clinics were around 80 per year. During the following year - that before the PrEP became widely available - they dropped sharply to 47 and were 43 in the year after PrEP started. Cases of recent HIV infection - acquired less than six months before testing - dropped similarly from about 30 a year before July 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 it was similarly attributed to increases in HIV testing and the proportion of people on antiretroviral therapy who are suppressed by viruses.
IST tests and results
The number of STI tests more or less mirrored in HIV tests increased at the same higher rate in people who took PrEP or who would continue to take PrEP. And gonorrhea diagnoses increased between mid-2014 and mid-2018, as they have elsewhere, from about 170 a quarter in June 2014 to over 300 a quarter at the beginning of PrEP in July 2017 and around 400 in the last quarter of 2017. The increases were much greater in the men who took PrEP! For the obvious reason! PrEP may even prevent some HIV infections, but it opens the door, with the forgiveness of Chiquinha Gonzaga, for STDs, and with an epidemic of gonorrhea almost without cure spreading, it makes a lot of sense to find ways to not use condoms!
Even among those who were “taking into account the possibility of using PrEP
Or, that they would adopt it, with 85 per quarter at the beginning of PrEP available to 160 per quarter in the last quarter of 2017. This is equivalent to using a credit card without a salary !!!
More Tests are the Cause. Yeah ... Do you know That Shadow of the Sieve?
This looks like a huge increase in gonorrhea in PrEP men, but it is almost entirely due to more testing. THE proportion of men who had STI tests diagnosed with gonorrhea was 8,05% during July 2016 to June 2017 in men who never used PrEP and 10,9% in men who started using PrEP the following year. In the following year, the rate was 7,25% in men who did not use PrEP and 11,9% in men who took PrEP. The difference between PrEP users and non-users is statistically significant, but changes from year to year are not. As the report puts it, "[There were] 318 more 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 2017 coincided with the human papillomavirus vaccine (HPV) being presented to gay men under 45, so that clinics had a double burden of new prescriptions. This has led many patients to need much longer consultations than usual. Some clinics have solved this problem by introducing pre-assessment interviews by nurses who have collected behavioral data, with doctors called only to give test results, prescribe PrEP if necessary, and explain dosage and compliance. 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 the results of the interpretation labs. Some doctors struggled with patients who had complex eligibility problems *, but these were resolved by doctors by creating “professional couple support systems”, such as so-called virtual clinics.
On the other hand, fewer people than expected traveled from England or elsewhere to obtain Scottish PrEP. *
When PrEP started, only the brand Truvada was available at a cost of £ 355 for 30 days, but the commissioners decided to buy generic drugs at a tenth of the price. These became available in October, although "this was subject to legal challenge". Another cost reduction and effectiveness measure adopted was the issuance of PrEP to patients on the day of their initial assessment, as in England. The report says that “occasional” patients they ended up having acute HIV that day and had to be removed, but they do not say how many.
Difficult to Define Whether the Result Is Due to PrEP
Is still difficult to say whether PrEP produced any further reduction in population-level HIV infections. There was a decrease in the proportion of HIV testers testing positive in July 2017 - June 2018 compared to the previous 12 months, from 0,4% of all testers to 0,3%, but no decrease in people who had acquired HIV recently. The “between one to four” people who got HIV despite being prescribed with PrEP would indicate an overall annual HIV incidence among all PrEP policyholders from 0,1% to 0,4%, indicating effectiveness at the group level. up to 75%, but PrEP is still too young for any population to be observable. * Eligibility - What is the problem with the eligibility of condom provision? Age and size. Once these “variables” are adjusted… * Scottish PrEP…. I don't see equivalent difficulties in the case of condoms…. £ 355…. Would the condom cost £ 1.00? Population Level! The condom, which I asked so much about not using, has minimized impact after population impact. What is the point in implementing PrEP, when establishing condom use is much cheaper and is based on exactly what I didn't have? Education regarding sexual and reproductive health. I was such an accomplished idiot that I considered STD 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, summaries and infographic.
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