We are in a particularly challenging phase of the pandemic. While they have been shown to be effective in reducing hospitalizations and serious illness, our best vaccines have failed to protect against infection. While Paxlovid has been an effective line of defense in treating breakthrough Covid-19 infections of those most at risk, we have yet to explore the potential of prophylactic drugs.
Prevention is always better than cure. Especially when more than a third of Covid-19 patients will develop long-lasting symptoms and some will experience symptoms severe enough to be disabled for many months, if not years†
HIV is another infectious disease that has eluded an effective vaccine, but after many years of research and investment in drug development, it is no longer a death sentence. I have long advocated that drug developers learn from HIV research and focus on developing combinations of small molecule antiviral drugs to prevent and treat Covid-19.
However, it is not enough to focus only on the development of prophylactic drugs. The drugs will become ineffective if there is hesitation around taking the drugs or a low level of adherence. With each global health crisis, it becomes clear that we need both medical solutions and the public health-focused behavioral and social change programs to implement them. Policymakers and public health officials need to work with social scientists to create education and outreach initiatives and restore trust in institutions. We also need to ensure equity and access to preventive treatments, especially in healthcare deserts and low socio-economic areas. No population is safe until all of us are.
A recent studyon the true effectiveness of pre-exposure prophylaxis in men at high risk of HIV infection in France shows how even a highly effective drug like PrEP can be weakened by a lack of adherence.
Pre-exposure prophylaxis (PrEP) for HIV has been shown to be highly effective in clinical trials, but less research has been done on its effectiveness when prescribed in real life to diverse populations. The authors of this study used a matched, nested case-control study in adult men at high risk of HIV infection between January 1, 2016 and June 30, 2020, using data from the French National Health Data System. Men diagnosed with new HIV infection before December 31, 2020 were individually matched with up to five controls for age, socioeconomic status, place of residence, calendar year, and length of follow-up.
Among a total of 46,706 subjects, 256 patients with HIV infection were identified and matched with 1,213 controls. PrEP users accounted for 29% of cases and 49% of controls. Real-world PrEP effectiveness was found to be generally 60%, extending to 93% for a high amount of PrEP consumption, and 86% if periods after discontinuation of PrEP are excluded.
The effectiveness of PrEP was significantly reduced in people under the age of 30 and in people with low socioeconomic conditions. Both groups showed low amounts of PrEP consumption and high rates of PrEP discontinuation.
Although this study shows that the effectiveness of PrEP appears to be lower in field conditions than reported in clinical trials. Lower effectiveness appears to be related to compliance. Strengthening efforts to improve monitoring of PrEP compliance is essential to ensure higher effectiveness of PrEP in a real world environment.
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