REPORT – 10 patients in half a day. The PrEP consultation (Pre-Exposure Prophylaxis) dedicated to people at high risk of HIV contamination is very popular at Saint-Louis Hospital (Paris). Report within the walls of a pioneering structure.
This consultation room looks like any other at first sight. The cramped and anonymous office is located within the infectious diseases department of the Saint-Louis hospital (Paris), directed by Pr Jean-Michel Molina. However, it is the starting point of a revolution in HIV prevention: since November 10, 2015, the PrEP (Pre-Exposure Prophylaxis) consultation has been held there. The doctors who hold it prescribe Truvada to people at high risk of contamination. Reporting at the heart of this pioneering service.
“I’ve been worried for 20 years”
The prevention of HIV by a drug is not self-evident in France. In January 2013, associations requested authorization for Truvada in this indication. It was only in January 2016 that the National Agency for the Safety of Medicines (ANSM) granted its Temporary Recommendation for Use (RTU) – which allows the use for 3 years. This is not to deny the usefulness of the condom, but to respond to a public health requirement. Since 2007, the number of discoveries of seropositivity has stabilized at 6,600 per year. This statistic hides a disparate reality: 42% of cases concern men who have sex with men (MSM). As a result, they are the main population targeted by PrEP.
Stan falls into this category. “I’ve been worried about having HIV for 20 years because I’ve had HIV-positive friends, lovers and boyfriends,” he breathes, arms crossed over his coat. The virus is present in our community in a significant way, there is no denying that. At 36, he is the average age of being diagnosed with HIV. This is what prompted him to go to the Saint-Louis consultation for the first time. It’s not the historic gray walls of the hospital that house it. As a symbol, the infectious diseases department is located in the basement of the building called “New Saint-Louis”. The man must first cross a staircase in order to reach it.
Deconstruct received ideas
The consultation begins with an interview with Khafil Moudachirou, AIDES activist and accompanist seconded to Saint-Louis Hospital. This man with a good-natured smile teaches users the PrEP on-demand regimen: antiretroviral tablets must be taken according to risk reports. With all the sweetness that emanates from him, he seizes the opportunity to address drug use, the prevention of other sexually transmitted infections (STIs) and risk taking. “The goal is to deconstruct the received ideas they may have about risky relationships. We alert them in particular to the fact that PrEP does not protect against other STIs,” he explains. Users are therefore encouraged to select the partners with whom they give up the condom in favor of Truvada: rather people they trust, who will warn of a possible STI.
Khafil Moudachirou, AIDES project manager: “ The guides are available at any time, via a telephone provided by the association. »
Stan, already well informed about PrEP, discusses specific topics with Dr. Diane Ponscarme. But the infectiologist never lets anyone go until the “final examination” has been passed. On the program, questions subtle enough to trap those who do not fully master the terms. And Stan fails. “Review the diagram with Khafil, you have to have integrated it automatically,” she insists.
The consultation of Dr Diane Ponscarme and Stan, user:
Stan leaves the room anyway with his Truvada prescription, but Khafil Moudachirou is waiting for him in the waiting room. Together, they review the diagram one last time on demand. In a month, he will return to Saint-Louis Hospital to take stock. Then, appointments will be scheduled every quarter.
“I developed a great weariness”
This day, ten men follow one another in the office of Diane Ponscarme. Amber necklace and burgundy neckerchief, she conducts her consultation with a masterful hand. Without detour or judgment, the infectiologist leads men to confide in their risk-taking. Philippe makes his third visit. He started taking PrEP “in the wild” in March 2015, without a prescription or medical follow-up. HIV-positive people on treatment sometimes share their Truvada with HIV-negative acquaintances. Aware of the risks of this method, Philippe joined the Saint-Louis consultation as soon as it opened.
“I never took pleasure with the condom. Over time, I developed a great weariness, he says. Wearing it consistently has become increasingly difficult. Now, as soon as I plan to have sex I take PrEP and if I wear a condom, I don’t continue the treatment. The on-demand scheme provides for taking two tablets up to two hours before intercourse, then one tablet within 24 hours and a final one within 48 hours. If intercourse does not take place, or with a condom, the second part of PrEP is not necessary.
A combined prevention tool
This is the strength of this new method of prevention: it completes the means already available. Sitting in a room in the day hospital that he occupies during the afternoon, Khafil Moudachirou confirms it: PrEP is not intended to supplant the condom. As proof: the stock available to users was well emptied in half a day. “It’s a prevention tool like any other, which falls within the framework of combined prevention,” he underlines.
Dedicated to people at high risk of contamination by #HIV, the PrEP consultation (Pre-Exposure Prophylaxis) is…
Posted by why doctor on Monday, February 22, 2016
The prescription is established for 3 months. The document is accompanied by a blood test. It will ensure that PrEP is well tolerated, but that there has been no contamination during this period. This is a mandatory condition listed in the temporary recommendation for use.
Dr. Ponscarme therefore begins by checking Philippe’s blood test, with particular attention to HIV serology and creatinine, a marker of kidney function. Indeed, Truvada can be toxic to the kidneys. The infectiologist also reviews other STIs to establish possible treatments. For each user, it checks vaccinations against viral hepatitis, past risk-taking. So many questions that allow you to develop a personalized strategy.
The consultation of Dr Diane Ponscarme and Philippe, user:
The pride of the participants in the Ipergay trial
They are the pioneers of PrEP in France. 400 men joined the Ipergay trial with the aim of evaluating the effectiveness of Truvada in preventing HIV infection. Thanks to their involvement, the drug received its Temporary Recommendation for Use. whydoctor met Franck, the first patient to join the clinical trial. “We are living through a real revolution,” he said. Like many, he did not expect a change of this magnitude. A “good surprise”, he admits. With caution, however. “We will see later if there is a drop in the number of HIV infections and other infections. In fact, information on STIs (gonococci, syphilis, chlamydia, etc.) within the framework of the PrEP consultation can promote the decline of these. This is what drives Franck to want permanent authorization for Truvada for HIV prevention. But not under any conditions. Medical supervision must remain as strict as that currently proposed.
Read more: Truvada for HIV prevention: PrEP not hitting all its targets
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