The potential role of derma‐venereologists in prescribing and managing pre‐exposure prophylaxis in Italy

Le résumé fourni par la source

The use of antiretroviral drugs by people who are human immunodeficiency virus (HIV)-uninfected but at high risk of acquiring the virus—pre-exposure prophylaxis (PrEP)—has proved to be an effective prevention strategy for reducing HIV transmission.1 Spreading knowledge about PrEP and improving its availability, accessibility and uptake are fundamental steps to reach the United Nations' goal of ending the acquired immune deficiency syndrome epidemic by 2030.2 In Europe, PrEP availability is complex and fragmented but dynamic. Over time, the number of countries providing PrEP free of charge has progressively increased, from 16 in 2020 to 26 as of the end of 2023. In 16 other countries, generic PrEP is available in healthcare settings, although it is not fully reimbursed. There are still 13 countries, mainly in Eastern Europe, that have not yet formally implemented PrEP programmes.3 In Italy, the use of a generic fixed-dose combination of tenofovir/emtricitabine was authorized for non-reimbursed PrEP in 2017.4 Since May 2023, PrEP has been made reimbursable by the National Health Service (NHS). However, the prescription has been limited to infectious disease specialists. The Italian protocol requires that every patient on PrEP is subjected to a quarterly serological screening for HIV and syphilis together with oropharyngeal, anorectal and first-void urine polymerase chain reaction (PCR) for Neisseria gonorrhoeae and Chlamydia trachomatis, while serologies for hepatitis A, B and C and the determination of serum creatinine should be repeated every 6 months. Moreover, PrEP users are supposed to receive counselling to reduce high-risk sexual behaviour, with the same frequency as screening for sexually transmitted diseases (STDs).5 In the United States, any healthcare provider licensed to write prescriptions can prescribe PrEP; specialization in infectious diseases is not required.6 In Europe, the situation is different in various countries: in Italy, Denmark, Finland and Portugal, PrEP is provided by infectious disease departments; in France, England and the Netherlands also by sexual health clinics and general practitioners; in Ireland and Germany, these services can be offered by a broader range of medical specialists.7 Infectious diseases clinics remain the most frequently reported setting where PrEP is available.3 Several studies indicate that this can constitute a barrier for the groups most needing PrEP.8 Although the expansion of PrEP has gained momentum, especially following the drug reimbursement authorisation by the NHS, today, in Italy, as in other European countries, there is still a gap between those who need PrEP and those who can access it. We believe that in Italy it would be necessary to extend the provision of PrEP to STD centres, managed by dermato-venereologists, who already provide services and support to the subjects most exposed to HIV and who have the skills to manage periodic STD screening. Before the advent of PrEP, it was estimated that 1 in 15 HIV-uninfected men who have sex with men with a confirmed diagnosis of rectal gonorrhoea or chlamydia and 1 in 30 with syphilis were subsequently diagnosed with HIV within just a year.9, 10 Having the opportunity to offer PrEP at the same time as the diagnosis and treatment of STDs allows us to significantly reduce the likelihood of HIV transmission. STD centres have the potential to reach persons at risk of HIV who are interested in accessing PrEP programmes through such centres. The possibility of prescribing PrEP by dermato-venereologists directly within their STD centres would also facilitate the periodic serological and microbiological screening, which is still often carried out at these centres even if the drug is prescribed outside by the infectious disease specialist. The final objective would be to make PrEP more accessible to everyone while guaranteeing the necessary periodic screening for HIV and other STDs. None. The article does not contain any information or images that could identify individuals. All available information is contained within the manuscript.

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