Contemporary challenges in Human Immunodeficiency Virus Pre-Exposure-Prophylaxis care in Belgium

Human Immunodeficiency Virus (HIV) Pre-Exposure-Prophylaxis (PrEP) is a very effective way to prevent HIV acquisition when correctly taken.1–4 It has been rolled-out in Belgium in 2017 for people at high risk of HIV acquisition like men-who-have-sex-with-men (MSM).5 Its uptake is continuously increasing, with just over 4000 patients having ever subscribed for PrEP through the Belgian public healthcare system between 2017 and 2019, 97.6% of them being MSM.6 Nevertheless, many barriers to PrEP care have been described such as logistical barriers, (fear of) side effects and financial issues7. The Promise project is a study that aims to optimize PrEP roll-out in Belgium to maximize impact on HIV incidence, addressing the barriers (potential) PrEP users face is one of the key objectives of this project. My work will focus on PrEP care users’ needs. This will be achieved by analyzing data collected from PrEP users of the Institute of Tropical Medicine and from an online cohort of PrEP users. A combination of quantitative and qualitative methodologies will be used to examine PrEP care service use and PrEP users preferences regarding PrEP care, to distinguish patterns of PrEP use and to assess the need for additional risk-reduction strategies among PrEP users.

PrEP users are particularly hit by sexually transmitted infections (STIs) like Gonorrhea, Chlamydia and Syphillis.8–13 Most PrEP guidelines, including Belgian ones, recommend 3-site (pharyngeal, urethral and ano-rectal) 3-monthly screening (3X3 screening) for those infections.14 While it has not been proven that screening for Neisseria Gonorrhoea (NG) and Chlamydia Trachomatis (CT) is effective in reducing the prevalence of these infections, screening leads to a very high antibiotic consumption15 which is in turn associated with the development of antimicrobial resistance (AMR).16 NG has developed resistance to all class of antimicrobials and is on its way to become untreatable.17 As a result, interventions are needed to reduce antimicrobial consumption (AMC), particularly in populations with a high AMC, like MSM on PrEP. The Gonoscreen study is the first randomized controlled trial (RCT) to assess if 3X3 screening for NG and CT among PrEP users is effective in reducing the incidence of these infections. If screening for CT/NG is not associated with a reduced incidence of these infections, then reducing screening could lead to a dramatic decrease in AMC. Such strategies, along with other antibiotic stewardship interventions, are urgently needed to slow down the emergence of AMR.