Interview with NCHIV speaker, Jean-Michel Molina
Professor Molina has worked in the field of HIV since the beginning of the European HIV epidemic in the early 1980s. Over time, Prof. Molina has seen the focus move from tackling opportunistic AIDS-related infections through to the treatment of HIV itself with antiretroviral drugs, and, more recently, to HIV prevention. Given that treatment of HIV is now highly effective if administered properly and cure is still some way off, Professor Molina felt it was time for research to focus on prevention: ‘If we cannot yet cure HIV, prevention is at least as important. Every patient in whom we can prevent HIV infection is as if we are curing these patients of HIV. ‘ He describes how, at a personal level, it was seeing new young patients come to his clinic for treatment every week that prompted him to get involved in prevention and want to change the way people thought about prevention.
With more than 40% of the 6000 new HIV diagnoses each year in France seen in men who have sex with men (MSM), Professor Molina’s IPERGAY study targeted MSM. Initially, the project faced a great deal of criticism from both the gay community and the medical field. But, he says, the IPERGAY results have brought everyone round. ‘Even at government level there is a clear understanding that this could be an important tool to curb the number of new infections in France and, in particular, Paris. What we’ve learnt from IPERGAY is that first, the incidence of HIV infection in these high-risk individuals was much higher than we thought, particularly in Paris compared to other cities in France. We have also realised how powerful these tools could be and how important it was to have the involvement of the community. This partnership with the community was critical in the success of the study’, according to Professor Molina.
After the results of the IPERGAY study were published, concerns were raised about the on-demand dosing. However, Molina claims that the difference between on-demand and daily dosing is no longer important, saying ‘some people will be better off with daily use; others with intermittent use. At the end of the day it’s the same drug, but our results offer more flexibility, with fewer adherence issues and people might therefore now be more willing to use it. With the IPERGAY results, we now have more options and Prep has become more attractive.’ He goes on to points out that the level of prevention in the IPERGAY trial was 100% in those on treatment, with the only two cases of infection occurring after 18 months in people who had stopped using PrEP. In Molina’s opinion, on-demand PrEP remains the way forward: ‘There’s a momentum now and you can’t go back. We’ve opened the door to on-demand and to moving away from daily dosing’.
Other objections to the use of PrEP have included the argument that people may become complacent about PrEP and condom use. Prof Molina admits that this was a concern, but given that not everyone chooses to use a condom anyway, he believes PrEP should be made available for high risk individuals as another option to prevent HIV acquisition. ‘PrEP will be as, if not more, effective in preventing HIV infection than condoms’, says Dr. Molina. He goes on to draw a comparison with preventing pregnancies, saying: ‘ Today people can choose between the condom and the contraceptive pill. It could be like that with HIV – you can use a condom or take PrEP. It doesn’t mean condoms shouldn’t be used, and we will have to wait to see what the consequences will be of less condom use, such as increased STIs. However, it’s not a good argument against making PrEP available.’
Dr. Molina says that the results of the European studies signaled a major change in the way people thought about PrEP, making other countries, including the US where the drug has already been approved for this indication, realise that PrEP really has a future. ‘Everywhere, people are now more willing to use it, more physicians are willing to set up demonstration projects and more people would want access to the drugs. I think it is fair to say now that PrEP is a very effective way of preventing HIV’.
Since the success of the study, all IPERGAY participants have been switched to PrEP and the team hopes to present the results early in 2016. An application for registration for the use of Truvada as PrEP should be filed before the end of the year. The question remains how it will be funded. Nonetheless, Professor Molina says that cost should not be a barrier to making a tool like PrEP available to those that need it, emphasizing that this will have to be dealt with on a country-by-country basis with the involvement of public health specialists to identify who can prescribe PrEP and in which settings. ‘It’s something new, so you have to train people, nurses, patients etc. in how to use it and use it well. It will be like HIV treatment, you need to educate patients and physicians, and once people are used to it they can probably manage themselves. However, you would need to monitor people, like we do with HIV infection. It’s still a treatment and you have to monitor any adverse events’, explains Dr. Molina.
Professor Molina feels it’s time for action, citing examples of people sharing PrEP drugs or ordering PrEP online without proper monitoring. ‘We have waited too long. We have the evidence; there’s no more need for discussion or studies to convince that it works. The discussion now should focus on how to implement and rapidly, because it would be a shame not to provide this critical tool to people at risk. We want people using PrEP properly, at the right dose, and with the right monitoring’.