HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?

published on June 19, 2008 in Travel Medicine Journal

Soon after the HI-Virus was discovered, condoms were found to be an effective measure to protect against HIV. The success of large-scale prevention campaigns, combined with the ‘treatment as prevention’ approach led to the control of this epidemic in most western countries. However, considering the numbers of new infections it seems as if condoms might not work for everyone and not in every situation. To use a condom, it is necessary to have one at hand and to act rationally in a moment of ecstasy. In this issue of Travel Medicine and Infectious Disease, authors Svenson et al. show, in a comprehensive meta-analysis, that a range of various types of people tend to have more risky sexual behavior with inconsistent condom use abroad [1]. Furthermore, the authors found that the impact of routine safe sex counseling while giving pre-travel advice is limited. It is time to reflect upon which prevention measures work best for which travelers and to consider new HIV prevention tools.

In 2012, the United States Food and Drug Administration approved a new form of HIV prevention: the pre-exposure prophylaxis (PrEP). PrEP refers to the use of antiretroviral medication to prevent HIV negative people from acquiring HIV. Large trials have shown high efficacy [2], especially among men who have sex with men (MSM). PrEP was also showed to be effective in women, but it turned out to be more challenging to reach protective concentrations of PrEP in the genital tract. Therefore, women must take PrEP longer until they are maximally protected against HIV and adherence to PrEP intake is even more important in this context [2]. According to the World Health Organization PrEP is recommended for populations with a risk higher than three per 100 person years to be infected with HIV [3]. In many high-risk countries like South Africa, Kenya or Thailand, PrEP became more and more important to fight the HIV epidemic. In most western countries the estimated risk of becoming HIV-infected is only higher than three per 100 person years in subpopulations of MSM and transgender people who have condomless sex with occasional partners and in other specific communities [4]. People who use PrEP should be monitored by specialized health care professionals who counsel regarding side effects and who also perform laboratory tests to rule out asymptomatic sexually transmitted infections (STI) - especially an unknown HIV infection [2]. PrEP can only prevent an HIV infection if taken correctly, but cannot prevent other STIs. However, condoms also cannot prevent other STIs either, for example, during oral sex for which they are almost never used. As a consequence, condoms are no longer recommended for oral sex by most authorities from various countries. On the other hand, there is solid evidence that good medical supervision in a PrEP program can lead to a reduction not only in HIV, but also in all other STIs among high risk populations, due to the detection and treatment of asymptomatic STIs [5].

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HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?

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