Announcements
On 6 June 2017, the World Health Organization (WHO) published updates to its ‘Essential Medicines List’ (EML). Read more here.

Extended deadline (from 1 July to 31 July) 2017 for call to submit papers on effectiveness and cost-effectiveness of screening and prevention of infectious diseases among newly arrived migrants in Europe. Read more here.

Eurosurveillance is on the updated list of the Directory of Open Access Journals and in the SHERPA/RoMEO database. Read more here.

Follow Eurosurveillance on Twitter: @Eurosurveillanc


In this issue


Home Eurosurveillance Edition  2017: Volume 22/ Issue 11 Article 5
Back to Table of Contents
Previous Download (pdf)
Next

Eurosurveillance, Volume 22, Issue 11, 16 March 2017
Letter
van Tienen, van de Vijver, Noori, Sönnerborg, and Boucher: Letter to the editor: Pre-exposure prophylaxis for HIV in Europe: The need for resistance surveillance

+ Author affiliations


Citation style for this article: van Tienen C, van de Vijver D, Noori T, Sönnerborg A, Boucher C. Letter to the editor: Pre-exposure prophylaxis for HIV in Europe: The need for resistance surveillance. Euro Surveill. 2017;22(11):pii=30483. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2017.22.11.30483

Received:03 March 2017; Accepted:15 March 2017

To the editor: In a recent paper by Hauser et al. in this journal, a prevalence of 10.8% of transmitted drug-resistant viruses was reported among newly diagnosed HIV cases in Germany in 2013 and 2014 [1]. The authors conclude that genotypic resistance testing remains important for treatment as well as HIV prevention. We comment on the use of pre-exposure prophylaxis (PrEP) in relation to drug resistance in HIV infections and the need for European surveillance of drug resistance.

PrEP with tenofovir and emtricitabine prevents new HIV infections in persons at high risk of acquiring HIV [2]. In 2016, the European Commission approved emtricitabine/tenofovir disoproxil once per day for PrEP. France and Norway are the only two countries in Europe fully reimbursing PrEP but many more are considering implementing PrEP pilot projects in 2017 and 2018 [3]. PrEP is cost effective with the current drug prices [4,5] and a generic version of tenofovir and emtricitabine is expected in 2017 or 2018, which may reduce the costs and lead to more widespread use of PrEP in Europe.

PrEP use also poses some challenges as the included drugs are part of the recommended first and second line regimens to treat HIV-infected individuals. The resistance patterns that develop against either drug in a situation of therapy failure are well known: the primary mutation selected by tenofovir that causes a diminished treatment response is the K65R amino acid substitution in the reverse transcriptase. In addition, the presence of multiple thymidine-associated mutations (TAMs) selected by zidovudine, a previously frequently used drug in HIV treatment, can affect the effect of tenofovir on the virus. In individuals failing emtricitabine (or the commonly used lamivudine)-containing regimens, the amino acid changes M184I/V are frequently seen [6]. Viruses with these mutations can be transmitted, resulting in the failure of tenofovir/emtricitabine-based PrEP [7,8].

The use of PrEP by individuals infected with HIV but unaware of this can lead to the generation of resistant viruses in these individuals. Transmission to, or selection in, an HIV-positive person on PrEP carries the risk of forward transmission of these resistant virus to other individuals (both on and off PrEP).

Therefore, we recommend surveillance on national level as well European level. As mentioned by Hauser et al., Germany has a mandatory notification system of new HIV diagnoses, but this is not the case in all European countries [1]. In addition, baseline genotypic resistance testing is not routinely performed in all countries. We recommend the surveillance network Strategy to Control Spread of HIV Drug Resistance (SPREAD) to collect these data [9]. SPREAD is organised in 28 countries by the European Society of Antiviral Research (ESAR) and monitors drug-resistant viruses in newly diagnosed individuals [10]. SPREAD can add the use of PrEP in the baseline questionnaire and install a registry within the existing SPREAD database, collecting data on selection of resistant viruses and treatment and/or prophylaxis failure due to PrEP use. In this way, we hope that outbreaks of PrEP-resistant viruses will be identified in a timely manner.

In conclusion, as PrEP for HIV prevention is expected to be rolled out in European countries in the near future, and considering the informal use of PrEP in the community, we suggest including variables on PrEP use in the European surveillance SPREAD programme, increasing the proportion of baseline resistance testing in newly diagnosed HIV infections and installing a registry on the selection of resistant viruses and failure of PrEP within the existing SPREAD database.


Note

Disclaimer: This paper is the view of the authors and not necessarily that of the agencies that they represent.

Conflict of interest

None declared.


References

  1. Hauser A, Hofmann A, Hanke K, Bremer V, Bartmeyer B, Kuecherer C,  et al.  National molecular surveillance of recently acquired HIV infections in Germany, 2013 to 2014. Euro Surveill. 2017;22(2):30436. DOI: 10.2807/1560-7917.ES.2017.22.2.30436 PMID: 28105988

  2. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L,  et al.  Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587-99. DOI: 10.1056/NEJMoa1011205 PMID: 21091279

  3. European Centre for Disease Prevention and Control (ECDC). Pre-exposure prophylaxis for HIV prevention in Europe. Stockholm: ECDC; 2016. Available from: http://ecdc.europa.eu/en/publications/Publications/pre-exposure-prophylaxis-hiv-prevention-europe.pdf

  4. Ross EL, Cinti SK, Hutton DW. Implementation and operational research: a cost-effective, clinically actionable strategy for targeting HIV preexposure prophylaxis to high-risk men who have sex with men.J Acquir Immune Defic Syndr. 2016;72(3):e61-7. DOI: 10.1097/QAI.0000000000000987 PMID: 26977749

  5. Nichols BE, Boucher CA, van der Valk M, Rijnders BJ, van de Vijver DA. Cost-effectiveness analysis of pre-exposure prophylaxis for HIV-1 prevention in the Netherlands: a mathematical modelling study.Lancet Infect Dis. 2016;16(12):1423-9. DOI: 10.1016/S1473-3099(16)30311-5 PMID: 27665989

  6. van de Vijver DA, Boucher CA. The risk of HIV drug resistance following implementation of pre-exposure prophylaxis.Curr Opin Infect Dis. 2010;23(6):621-7. DOI: 10.1097/QCO.0b013e32833ff1e6 PMID: 20847692

  7. Knox DC, Tan DH, Harrigan PR, Anderson PL. HIV-1 Infection with multiclass resistance despite preexposure prophylaxis (PrEP). Conference on Retroviruses and Opportunistic Infections (CROI); 22-25 Feb 2016; Boston. Available from: http://www.croiconference.org/sessions/hiv-1-infection-multiclass-resistance-despite-preexposure-prophylaxis-prep

  8. Grossman H. Newly acquired HIV-1 infection with multi-drug resistant (MDR) HIV-1 in a patient on TDF/FTC-based PrEP. Research for Prevention; 17-21 Oct 2016; Chicago.

  9. European Society for translational Antiviral Research (ESAR). SPREAD Surveillance Program. Utrecht: ESAR. [Accessed: 2 Mar 2017]. Available from: http://www.esar-society.eu/spread-surveillance-program

  10. Hofstra LM, Sauvageot N, Albert J, Alexiev I, Garcia F, Struck D,  et al. , SPREAD Program. Transmission of HIV drug resistance and the predicted effect on current first-line regimens in Europe.Clin Infect Dis. 2016;62(5):655-63. DOI: 10.1093/cid/civ963 PMID: 26620652



Back to Table of Contents
Previous Download (pdf)
Next

The publisher’s policy on data collection and use of cookies.

Disclaimer: The opinions expressed by authors contributing to Eurosurveillance do not necessarily reflect the opinions of the European Centre for Disease Prevention and Control (ECDC) or the editorial team or the institutions with which the authors are affiliated. Neither ECDC nor any person acting on behalf of ECDC is responsible for the use that might be made of the information in this journal. The information provided on the Eurosurveillance site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her physician. Our website does not host any form of commercial advertisement. Except where otherwise stated, all manuscripts published after 1 January 2016 will be published under the Creative Commons Attribution (CC BY) licence. You are free to share and adapt the material, but you must give appropriate credit, provide a link to the licence, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Eurosurveillance [ISSN] - ©2007-2016. All rights reserved
 

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.