AIDS Q&A
愛滋Q&A
人們需要從 PEP 到 PrEP 之間的通道——然後再返回

羅傑‧佩博迪 / 2024 年 3 月 5 日 / aidsmap

在反轉錄病毒和伺機性感染會議 (CROI 2024) 上專家表示,提供暴露後預防 (PEP) 和暴露前預防 (PrEP) 的服務,需要在這兩種預防愛滋病毒感染的方法之間建立更牢固的聯繫,以幫助使用一種方法的人能獲得另一種方法。儘管尋求 PEP 的總人數仍然有限,但近年來,許多尋求 PEP 的人之前都曾接受過 PrEP 處方。 但由於某種原因,他們沒有持續使用它,現在覺得需要採取緊急措施。 同時,目前許多接受 PEP 治療的人可能在未來幾週和幾個月內再次需要保護。

美國疾病管制與預防中心 (CDC) 的瑪麗·坦納 (Mary Tanner) 博士指出,在美國,PEP 和 PrEP 之間存在脫節。 在 PrEP 的第一個十年(從 2013 年開始),使用量從零穩定地成長到 2022 年的 45 萬左右。在同一時期,PEP(舊方法)的使用幾乎沒有變化。 每年約有 14,000 至 18,000 張 PEP 處方。 平均而言,使用量每年僅成長 1.3%。 相比之下,PrEP 的使用量每年增加 33%。除了未充分利用外,PEP 也不一定被最需要的人使用。 儘管五分之四的愛滋病毒新診斷是男性,但 PEP 處方中只有一半是針對男性的。 雖然超過一半新的愛滋病毒診斷係發生在該國南部,但卻只有三分之一的 PEP 處方是在那裡開出的。

Tanner 博士告訴aidsmap,PEP 和 PrEP 服務之間需要加強聯繫。 PEP 和 PrEP 屬於同一連續體,使用其中一種的人需要了解另一種方法。 但是針對各別預防方法卻都發布了單獨的指南,並且沒有強調它們之間的關聯。英國的指南建議從 PEP 平穩過渡到 PrEP,迪恩街 56 號的 Gary Whitlock 醫生報告了他的診所為確保遵循建議而開展的工作。 這家倫敦性健康診所提供英格蘭所有 PEP 處方的四分之一和三分之一的 PrEP 處方。

自 2021 年 1 月起,每個接受 PEP 的人都會獲得一個月的 PrEP,在完成 28 天的療程後開始使用。 這是在「選擇性退出」的基礎上提供的——換句話說,只有當人們說他們不想要的時候才不會提供。

2022 年 3 月和 4 月,迪恩街 56 號為 282 名同性戀和雙性戀男性以及 6 名跨性別女性提供了 PEP。 (此分析未包括其他人口群體。)一半年齡在 25 歲至 37 歲之間,一半以上出生在海外,63% 是白人。

對於 58% 的人來說,這不是他們第一次去 Dean Street診所,44% 的人以前使用過 PrEP。 他們的性別沒有受到 PrEP 覆蓋的最常見原因是當時沒有 PrEP 供應,可能是由於難以進入診所或其他障礙 (30%); 選擇暫停 PrEP(25%); 自發性性行為(15%); 以及服用了錯誤的劑量(13%)。

四分之三的接受 PEP 治療的人 (212) 接受了 PrEP 的提議,超過一半 (114) 後來回到迪恩街 56 號診所進行 PrEP 預約。 隨後開始 PrEP 的 PEP 使用者更有可能以前使用過 PrEP 並就診於迪安街 56 號,並且在尋求 PEP 時更有可能具有多個性伴侶。 惠特洛克說,提供 PrEP 為更廣泛地討論 HIV 預防方案打開了大門,包括檢查在過去或目前的 PrEP 使用者是否了解使用它的最佳方法。

一些會議代表擔心,如果人們立即從 PEP 轉為 PrEP,檢測可能會錯過 HIV的 血清轉換。 接觸抗愛滋病毒藥物可以抑制抗體的產生,這在極少數情況下意味著一站式的即時檢測可能會遺漏掉感染。 而PEP 和 PrEP 之間的間距可能會避免這種非常低的風險,但也意味著會錯過為確實需要愛滋病毒預防的人提供持續保護的機會。

參考文獻:

Tanner MR et al.  HIV 暴露後預防處方趨勢:美國,2013-2022 年。 第 31 屆反轉錄病毒和伺機性感染會議,丹佛,摘要 1131,2024 年

Whitlock GG et al.  PEP2PrEP:一種有效的降低愛滋病毒風險的策略。 第 31 屆反轉錄病毒和伺機性感染會議,丹佛,摘要 1131,2024 年。

People need pathways from PEP to PrEP – and back again

Roger Pebody / 5 March 2024 / aidsmap

Services providing post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) need to build stronger connections between these two ways of preventing HIV infection, so as to help people who’ve used one method to access the other, according to experts at the Conference on Retroviruses and Opportunistic Infections (CROI 2024).

While the overall numbers of people seeking PEP remain limited, in recent years many of those accessing it have previously been prescribed PrEP. But for one reason or another, they didn’t use it consistently, and now feel the need for an emergency measure. At the same time, many people currently prescribed PEP are likely to need protection again in the coming weeks and months.

Dr Mary Tanner of the Centers for Disease Control and Prevention (CDC) pointed to a disconnect between PEP and PrEP in the United States. During PrEP’s first decade (from 2013), uptake grew steadily from zero to around 450,000 in 2022.

Over the same time period, usage of PEP – the older method – barely changed. Each year there were between around 14,000 and 18,000 PEP prescriptions. Averaged out, usage increased by just 1.3% a year. In contrast, PrEP usage increased by 33% each year.

As well as being under-used, PEP isn’t necessarily used by those in the greatest need. Whereas four in five new HIV diagnoses are in men, only half of PEP prescriptions are for men. While over half of new HIV diagnoses occur in the south of the country, only a third of PEP prescriptions are issued there.

Dr Tanner told aidsmap that stronger connections between PEP and PrEP services are needed. PEP and PrEP are on the same continuum, and people using one of them need to know about the other. But separate guidelines are issued for each prevention method, and they do not emphasise linkages between them.

Guidelines in the United Kingdom recommend a smooth transition from PEP to PrEP, and Dr Gary Whitlock of 56 Dean Street reported on his clinic’s work to ensure that the recommendation is followed. This London sexual health clinic provides a quarter of all PEP prescriptions and a third of all PrEP prescriptions in England.  

Since January 2021, everyone receiving PEP is offered a one-month supply of PrEP, to be started when they complete the 28-day course. This is provided on an ‘opt out’ basis – in other words it is only not provided if the person says they do not want it.

In March and April 2022, 56 Dean Street provided PEP to 282 gay and bisexual men and six transgender women. (Other demographic groups were not included in this analysis.) Half were between the ages of 25 and 37, over half were born overseas, and 63% were White.

For 58%, this wasn’t the first time they had attended Dean Street, and 44% had used PrEP before. The most common reason for their sex not having been covered by PrEP were not having a PrEP supply at the time, perhaps due to difficulties accessing the clinic or other barriers (30%); having chosen to take a break from PrEP (25%); spontaneous sex (15%); and having taken the wrong dose (13%).

Three-quarters of people prescribed PEP (212) accepted the offer of PrEP, and over half (114) later came back to 56 Dean Street for a PrEP appointment. PEP users who subsequently started PrEP were more likely to have previously used PrEP and attended 56 Dean Street, and were more likely to have had multiple sexual partners on the occasion they sought PEP for. Whitlock said that offering PrEP opens the door to a wider discussion about HIV prevention options, including checking that former or current PrEP users understand the best way to use it.

Some conference delegates had concerns about the possibility of an HIV seroconversion being missed by testing if people switch immediately from PEP to PrEP. Exposure to antiretrovirals can suppress the production of antibodies, which very occasionally means that a point-of-care test misses an infection. Having a gap between PEP and PrEP might avoid this very low risk, but would also miss the opportunity of providing ongoing protection to people with a demonstrated need for HIV prevention.

References

Tanner MR et al. HIV Post-Exposure Prophylaxis Prescription Trends: United States, 2013-2022. 31st Conference on Retroviruses and Opportunistic Infections, Denver, abstract 1131, 2024.

Whitlock GG et al. PEP2PrEP: an effective HIV risk-reduction strategy. 31st Conference on Retroviruses and Opportunistic Infections, Denver, abstract 1131, 2024.

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