Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study

Andrew E Grulich; Rebecca Guy; Janaki Amin; Fengyi Jin; Christine Selvey; Jo Holden; Heather-Marie A Schmidt; Iryna Zablotska; Karen Price; Bill Whittaker; Kerry Chant; Craig Cooper; Scott McGill; Barbara Telfer; Barbara Yeung; Gesalit Levitt; Erin E Ogilvie; Nila J Dharan; Mohamed A Hammoud; Stefanie Vaccher; Lucy Watchirs-Smith; Anna McNulty; David J Smith; Debra M Allen; David Baker; Mark Bloch; Rohan I Bopage; Katherine Brown; Andrew Carr; Christopher J Carmody; Kym L Collins; Robert Finlayson; Rosalind Foster; Eva Y Jackson; David A Lewis; Josephine Lusk; Catherine C O'Connor; Nathan Ryder; Emanuel Vlahakis; Phillip Read; David A Cooper; Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group

doi:10.1016/S2352-3018(18)30215-7

Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study

Lancet HIV. 2018 Nov;5(11):e629-e637. doi: 10.1016/S2352-3018(18)30215-7. Epub 2018 Oct 17.

Authors

Andrew E Grulich¹, Rebecca Guy², Janaki Amin³, Fengyi Jin², Christine Selvey⁴, Jo Holden⁴, Heather-Marie A Schmidt⁴, Iryna Zablotska⁵, Karen Price⁶, Bill Whittaker⁴, Kerry Chant⁴, Craig Cooper⁷, Scott McGill⁸, Barbara Telfer⁴, Barbara Yeung², Gesalit Levitt², Erin E Ogilvie², Nila J Dharan², Mohamed A Hammoud², Stefanie Vaccher², Lucy Watchirs-Smith², Anna McNulty⁹, David J Smith¹⁰, Debra M Allen¹¹, David Baker¹², Mark Bloch¹³, Rohan I Bopage¹⁴, Katherine Brown¹⁵, Andrew Carr¹⁶, Christopher J Carmody¹⁷, Kym L Collins¹⁸, Robert Finlayson¹⁹, Rosalind Foster²⁰, Eva Y Jackson²¹, David A Lewis²², Josephine Lusk²³, Catherine C O'Connor²⁴, Nathan Ryder²⁵, Emanuel Vlahakis²⁶, Phillip Read²⁷, David A Cooper²; Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group

Collaborators

Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group:
Don Smith, Catriona Ooi, Sarah Martin, Tuck Meng Soo, David Templeton, David Townson, Brad Forssman, Nick Doong, Gai Han Thai, Ben Anderson, Hugh MacLeod, Nicolas Parkhill

Affiliations

¹ The Kirby Institute, University of New South Wales, Sydney, NSW, Australia. Electronic address: [email protected].
² The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.
³ Department of Health Systems and Populations, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.
⁴ New South Wales Ministry of Health, Sydney, NSW, Australia.
⁵ Western Sydney Sexual Health Centre and Sydney Medical School-Westmead, University of Sydney, Sydney, NSW, Australia.
⁶ ACON, Sydney, NSW, Australia.
⁷ Positive Life NSW, Sydney, NSW, Australia.
⁸ Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, NSW, Australia.
⁹ Sydney Sexual Health Centre, Sydney, NSW, Australia.
¹⁰ North Coast HIV/Sexual Health Services, Lismore, NSW, Australia.
¹¹ Holden Street Clinic, Gosford, NSW, Australia.
¹² East Sydney Doctors, Darlinghurst, NSW, Australia.
¹³ The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Holdsworth House Medical Practice, Darlinghurst, NSW, Australia.
¹⁴ The Albion Centre, Surry Hills, NSW, Australia.
¹⁵ Illawarra Sexual Health Service, Wollongong, NSW, Australia.
¹⁶ St Vincent's Hospital, Darlinghurst, NSW, Australia.
¹⁷ Liverpool Sexual Health Clinic, Liverpool, NSW, Australia.
¹⁸ Albury Sexual Health Service, Albury, NSW, Australia; Brookong Sexual Health Centre, Wagga Wagga, NSW, Australia.
¹⁹ Taylor Square Private Clinic, Surry Hills, NSW, Australia.
²⁰ Clinic 16, Northern Sydney Sexual Health, St Leonards, NSW, Australia.
²¹ Nepean Blue Mountains Local Health District, Department of Sexual Health, Penrith, NSW, Australia.
²² Western Sydney Sexual Health Centre and Sydney Medical School-Westmead, University of Sydney, Sydney, NSW, Australia; Marie Bashir Institute for Biosecurity and Infectious Diseases, University of Sydney, Sydney, NSW, Australia.
²³ Short Street Clinic, Kogorah, St George Hospital, NSW, Australia.
²⁴ RPA Sexual Health, Camperdown, NSW, Australia.
²⁵ The Kirby Institute, University of New South Wales, Sydney, NSW, Australia; Hunter-New England Sexual Health, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
²⁶ Coffs Harbour Sexual Health, Coffs Harbour, NSW, Australia.
²⁷ Kirketon Road Centre, Kings Cross, NSW, Australia.

PMID: 30343026
DOI: 10.1016/S2352-3018(18)30215-7

Abstract

Background: HIV pre-exposure prophylaxis (PrEP) is highly effective in men who have sex with men (MSM) at the individual level, but data on population-level impact are lacking. We examined whether rapid, targeted, and high-coverage roll-out of PrEP in an MSM epidemic would reduce HIV incidence in the cohort prescribed PrEP and state-wide in Australia's most populous state, New South Wales.

Methods: The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study is an implementation cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine as HIV PrEP. We recruited high-risk gay men in a New South Wales-wide network of 21 clinics. We report protocol-specified co-primary outcomes at 12 months after recruitment of the first 3700 participants: within-cohort HIV incidence; and change in population HIV diagnoses in New South Wales between the 12-month periods before and after PrEP roll-out. The study is registered with ClinicalTrials.gov, number NCT02870790.

Findings: We recruited 3700 participants in the 8 months between March 1, 2016, and Oct 31, 2016. 3676 (99%) were men, 3534 (96%) identified as gay, and 149 (4%) as bisexual. Median age was 36 years (IQR 30-45 years). Overall, 3069 (83%) participants attended a visit at 12 months or later. Over 4100 person-years, two men became infected with HIV (incidence 0·048 per 100 person-years, 95% CI 0·012-0·195). Both had been non-adherent to PrEP. HIV diagnoses in MSM in New South Wales declined from 295 in the 12 months before PrEP roll-out to 221 in the 12 months after (relative risk reduction [RRR] 25·1%, 95% CI 10·5-37·4). There was a decline both in recent HIV infections (from 149 to 102, RRR 31·5%, 95% CI 11·3 to 47·3) and in other HIV diagnoses (from 146 to 119, RRR 18·5%, 95% CI -4·5 to 36·6).

Interpretation: PrEP implementation was associated with a rapid decline in HIV diagnoses in the state of New South Wales, which was greatest for recent infections. As part of a combination prevention approach, rapid, targeted, high-coverage PrEP implementation is effective to reduce new HIV infections at the population level.

Funding: New South Wales Ministry of Health, Gilead Sciences.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Adult
Aged
Anti-HIV Agents / administration & dosage
Bisexuality
Emtricitabine, Tenofovir Disoproxil Fumarate Drug Combination / administration & dosage
HIV Infections / diagnosis
HIV Infections / epidemiology
HIV Infections / prevention & control*
Homosexuality, Male
Humans
Incidence
Male
Medication Adherence
Middle Aged
New South Wales / epidemiology
Pre-Exposure Prophylaxis / methods
Pre-Exposure Prophylaxis / statistics & numerical data*
Prospective Studies
Risk Assessment
Sexual and Gender Minorities*
Young Adult

Substances

Anti-HIV Agents
Emtricitabine, Tenofovir Disoproxil Fumarate Drug Combination

Associated data

ClinicalTrials.gov/NCT02870790