Patients’ views on PrEP not straightforward

Against this backdrop, we recommend reading the article by Young, Flowers and McDaid.4 This qualitative study used focus groups and indepth interviews of men who have sex with men (MSM) and African migrants in Scotland to seek views on PrEP and its use. The study participants appeared to demonstrate both confusion and suspicion about PrEP efficacy statistics. Some appeared to be wary of ‘things on the internet’ (even questioning whether the US Food and Drug Administration was a reputable recommendation) and felt put off Truvada by the risk of side effects. Interestingly, many respondents seemed to feel that PrEP was not for them, something to be used by other, more risky individuals. The impressions from reading this paper are that clinicians will face diverse views and levels of knowledge about PrEP, with plenty of opportunity for disconnect between the real and perceived benefits and risks.

PrEP resistance unlikely?

Another PrEP paper with importance for clinicians is a report from the iPrEx study on HIV drug resistance.5 In the active Truvada arm (n=1226) there were 48 infections, of which only eight occurred in the presence of detectable circulating drug levels. Postseroconversion samples from these 48 patients were tested using standard HIV genotype and phenotype assays as well as deep sequencing methods. Only two patients in the active arm showed any drug resistance (the minor lamivudine mutation M184I), and through serial virological and pharmacological assays the authors concluded that drug resistance in seroconverters ‘was limited to those initiating PrEP with unrecognized infection’. Very reassuring, perhaps, but it does not completely close the door on emergent drug-resistant HIV cases, unless users of PrEP abstain from all HIV risk activities during the HIV testing window period and start PrEP immediately after their negative test result.

Gonorrhoea continues to keep us ‘on our toes’

The interim results of PROUD are likely to show high rates of sexually transmitted infections (STIs) among participants. Again, these data are likely to be public by the time of publication. Therefore, clinicians may soon face frequent presentations with STIs in MSM using PrEP, and their sexual partners, and with this will come the inevitable threat of drug resistance. Multidrug-resistant gonorrhoea has recently been reported from Australia.6 The novel A8806 strain was identified in late 2013 in a young European woman known to have travelled to Sydney and central and north-eastern Australia. This strain joins two others reported in the past 5 years: H041, identified in Japan, and F89, reported in MSM in Spain and France. All three were resistant to ceftriaxone, penicillin G and ciprofloxacin, and susceptible to spectinomycin, although the A8806 differed in being susceptible to azithromycin. The travel history of the patient identified in Australia suggests that the geographical origins of A8806 may never be identified, but the same or similar strains of gonorrhoea will almost certainly appear in the UK and elsewhere over the next few years. It is hard to know to what extent the title of a recent review Blomquist et al is alarmist.7 Certainly this makes fascinating and essential reading for those interested in this question who want to prepare for more bad news on bacterial STIs.

Finally, we are presumably not alone in receiving frequent emails soliciting contributions to open access journals of dubious stature. We were amused to read a blog8 describing how a researcher at Federation University Australia's School of Engineering and Information Technology submitted a paper to the International Journal of Advanced Computer Technology containing only the repeated phrase ‘Get me off your ****ing mailing list’. The author was promptly rewarded with a one-word peer review (‘Excellent’) and the opportunity to send a small fee and await publication.