HIV prevention therapy loses 39% of patients in 4 years

Since 2018, 39% of users of Prep (pre-exposure prophylaxis) in Brazil have discontinued this way of avoiding HIV infections. Among current users, young people and people with low education represent a small number of patients seen.

Prep consists of taking the combination of the antiretrovirals tenofovir and emtricitabine, which are effective drugs against HIV, daily. By doing so, the user avoids infection by the virus.

The method was approved for incorporation into the SUS (Sistema Único de Saúde) in May 2017. According to data from the Prep Panel, linked to the Ministry of Health, in January 2018 the method had more than 64,000 patients attended. In April this year, the number dropped to 39,000.

The Ministry of Health says, in a note to the Sheet, that Prep should be used while the person is at risk of HIV infection. In addition, the folder states that it takes measures to reduce access barriers, such as providing teleservice for service users.

Studies indicate high efficacy of the method: one of them concluded that Prep reduced the incidence of HIV by 95% in participants with detectable blood levels of the drug – that is, with constant adherence to prevention.

Therefore, the data indicating the decline in prophylaxis worries specialists. “We were not able to have good coverage of the use of Prep. It would have to be bigger and reach younger people”, says Alexandre Grangeiro, former director of the national HIV/AIDS program and scientific researcher at the USP School of Medicine.

Grangeiro coordinates studies on Prep in adolescents and adults. He says that prophylaxis needs to be used widely to reduce the incidence of the virus. “If a person uses Prep, they are only protecting themselves.”

“It is not enough to start Prep, it is necessary to remain over time. This high rate of interruption decreases the effectiveness of prophylaxis from the point of view of reducing incidence”, he adds.

He draws attention to the need for greater dissemination of the method, especially among younger people. According to him, the risk of HIV infection is higher in the early years of sexual life and, therefore, younger people are a high-risk group.

According to the Prep panel, of current prophylaxis users, only 12% are people between the ages of 18 and 24. In adolescents, Prep for over 15 years was indicated in a December 2021 recommendation by Conitec (National Commission for the Incorporation of SUS Technologies).

Availability for this public is still being implemented, says the Ministry of Health. “Prep’s clinical protocol is in the process of being updated and will have strategies to address the younger audience.”

The little participation of younger people in the use of Prep is also highlighted by Maria Amélia Veras, professor at the department of collective health at the Faculty of Medical Sciences at Santa Casa de São Paulo. She states that an educational program that informs about prophylaxis is important to avoid low adherence to the method. “This needs to go to schools.”

In fact, schooling is a point that draws attention in Prep user data. Currently, 72% of those using the service have 12 years or more of education. On the other hand, people with 0 to 3 years of formal education represent about 1%.

Reasons for dropping out of prep

Regarding the 39% drop in users in the last four years, Veras advocates an in-depth investigation. “The data generates an alert. It will fit […] identify who are the people who discontinued and what are the reasons.”

The teacher says that the interruption may be associated with a change in the behavior of users. An example is the beginning of a monogamous relationship where the partners test negative for HIV.

However, other reasons may be material. One case is if the person stopped using the service due to lack of money to travel to health centers. There are also problems related to the routine of each person, as it is necessary to undergo periodic examinations and go to dispensing locations to receive the medication.

“It is necessary to think about the barriers that can be material in the sense of people not being able to reach the health units”, says Veras.

This was the situation of attendant Gabriel de Paula, 19. As soon as he turned 18, he started a more constant sex life and saw in Prep a way to protect himself from HIV. Before that, the young man knew little about prophylaxis.

He says that starting the drug was easy. Keeping up with the routine of going to the health center that served him was also not difficult at first – even though the journey took around two hours.

The scene changed when he changed his work schedule. The center that served him only worked in the afternoon. At first, the young man only worked in the morning, but when he started working in the afternoon, it became difficult.

“I didn’t use it for a month, I couldn’t get it because of the routine”, he says.

What does the Ministry of Health say?

In notes sent to Sheet, the Ministry of Health says that Prep should be used when there is a risk of HIV infection and that it has taken measures to facilitate access and continuity. One of the actions was the expansion of the drug dispensing time from 1 to 4 months. “The initiative reduces the frequency with which users go to health services, making it easier to maintain the use of prophylaxis.”

The ministry adds that there is the use of teleservice to assist in the access and maintenance of Prep and that it holds workshops in the states to train health professionals. It also states that the search for prophylaxis has gone up. “Between March 2021 and April 2022, the number of Prep users doubled.”

Asked about the reasons that led to the discontinuation of users of prophylaxis between 2018 and 2022, the folder says that the interruption should be discussed by the patient with a health professional. For those who stop using prophylaxis, the Ministry of Health recommends having an HIV test within four weeks of stopping.

How does Prep work?

Prophylaxis consists of the antiretrovirals tenofovir and emtricitabine combined in one tablet. The user consumes one pill a day to prevent HIV replication if exposed to the virus. On the first day of using Prep, the person takes two pills, according to a review by Conitec.

Who is it recommended for?

Some groups are prioritized for Prep use, such as men who have sex with men, sex workers, and trans women. However, in a 2021 report, Conitec explains that prophylaxis is considered for any adult with an active sex life, noting aspects such as sexual practices, number of partnerships, inconsistent condom use and personal desire to adhere to Prep.

How to start using Prep?

The first step is to go to a public health service that offers prophylaxis. The Ministry of Health provides a website with the addresses. In the service, professionals talk to the person to explain about Prep and understand their sexual practices. Some tests are also performed – seropositive individuals are not suitable for prophylaxis, for example.

After starting with Prep, is it possible to abandon other forms of prevention?

Prep is part of combination prevention, a model based on different methods to prevent HIV transmission. Other mechanisms of combination prevention are the use of condoms and constant testing for STIs. In addition, Prep is effective only in preventing HIV. For other ISTs, this method does not prevent transmission.