by Roberta Cavaglià
A few weeks after the International AIDS Day, announced as every year on December 1, the Istituto Superiore di Sanità (ISS) released the data on the new diagnoses of HIV infection in Italy. “Compared to 2019, the number of new HIV diagnoses has almost halved,” explains Barbara Suligoi, head of the ISS AIDS Operations Center in the official press release, “And this is most likely due to the Covid-19 pandemic and the consequent restrictions on circulation and aggregation”. If in fact in 2019 the number of new cases was 2.531, last year it fell to 1,303, confirming a downward trend that has continued since 2012.
However, as the Italian league for the fight against AIDS, this is not a totally comforting result: the national survey system has for some time presented various critical issues – of which only some related to the pandemic – concerning the absence of data on the total number of tests performed, the lack of communication between the registers of HIV and AIDS cases and delays in notification of reports. The same News bulletin of the ISS specifies on several occasions that, in addition to the restrictions, the new diagnoses of 2020 could be underestimated due to the reduced number of tests carried out: the pandemic has in fact limited not only spontaneous access to the test, but also the offer of testing by health services and organizing screening initiatives. However, what is of particular concern is the type of new diagnoses: 60% arrive late, when people already have a severe immune situation or symptoms of AIDS.
“This delay affects the effectiveness of antiviral therapies,” comments Dr. Suligoi. “While antiviral therapy initiated at an early stage of infection and in a young person allows a quality and life expectancy similar to that of a person without HIV, a late diagnosis and therefore a late start of therapy reduces the chances of success” he concludes. Furthermore, the so-called late presenters they may have unintentionally transmitted HIV to other people, fueling a flood of undetected cases that, according to the ISS, range from 13,000 to 15,000 diagnoses.
There are prevention tools: in Italy, however, not all of them are promoted in the area as the National AIDS Plan 2017-2019, which has now expired for two years. These include pre-exposure prophylaxis (PrEP), a drug that protects against HIV in the event of a risky relationship with people who are HIV-positive and not yet on therapy. Authorized by the European Medicines Agency (EMA) in 2016, PrEP consists of a single tablet containing two medicines, tenofovir DF and emtricitabine, and which can be taken continuously or as needed, following a specific dosing schedule. It is prescribed by an infectious disease specialist after having performed a series of tests against HIV and other sexually transmitted diseases: the same tests are repeated every three months to monitor the user’s health. The original drug is called Truvada and is produced by the US biopharmaceutical company Gilead Sciences: in Italian pharmacies there are two generic versions that cost around 60 euros for 30 tablets. Although it has been prescribed since 2017, PrEP is currently not reimbursed by the national health system.
“I can’t afford to spend 60 euros every month, so I’m forced into the modality on demand, which for the way I am is not the best », says Salvo Maugeri, volunteer of PLUS and BLQ checkpoint counselor, who started taking PrEP in 2019. In many European states such as France, Spain, Portugal, Germany, Denmark and Croatia, PrEP is completely free: the centers that prescribe it in Italy, on the other hand, can only cover the cost of visits and control tests, while the purchase of the drug remains borne by the user. To date, “PrEP is an elite prevention tool, which represents a problem for the most fragile people and for the very young, who are however more exposed to the risk of contracting the HIV virus”, explains Daniele Calzavara, coordinator of the Milano Check Point, the Italian out-of-hospital center that follows the largest number of PrEP users (about 600).
“Pre-exposure prophylaxis has shown a high reduction in risk, its massive use would drastically reduce HIV infections but difficulties remain in accessing and adhering to therapy”, explained Silvia Nozza, infectious disease specialist at the San Hospital Raffaele of Milan during the 13th edition of the “ICAR Congress – Italian Conference on AIDS and Antiviral Research”, organized in Riccione with the patronage of Simit, the Italian Society of Infectious and Tropical Diseases. However, it reports the Health Newspaper, if it is true that PrEP protects against HIV infections, if other protections are eliminated there could be the risk of contracting other Sexually Transmitted Infections (STIs): “in fact, an increase of about 25% of STIs is estimated in subjects who do use of PrEP, although this data is also fueled by a fictitious element, given that those who access prophylaxis undergo regular tests every 3-4 months which the general population does not undergo “.
“We believe, and research shows it, that PrEP is essential to achieve the Sustainable Development Goals set by the UN for 2030, and among these the defeat of AIDS»Says Calzavara. In Italy, however, “to have official data on the diffusion of PrEP it would be necessary to have an interest that neither politics nor health care have”, comments Sandro Mattioli, president of the BLQ checkpoint, the first centro community based peer oriented in Italy, open since 2015. It has a dedicated PrEP desk since 2018 which currently follows around 150 people, but “the requests are constantly increasing, to the point that we have had to activate a waiting list”.
Furthermore, there are still many prejudices related to PrEP. “There are those who treat you as if you are more dangerous than others and I have often read about Grindr [ndr, la più grande app di social netwrok per gay, bi, trans e queer] “no prep” among the various things written on the presentation of a person’s profile “, says Mirco Costacurta, PhD student in Social Sciences at the University of Padua and screenwriter of the short film on HIV”not detectable“. Another stereotype linked to PrEP concerns the alleged promiscuity and irresponsibility of those who use it. In reality, “as my story and that of many other people shows, PrEP is a taking of responsibility towards ourselves and ourselves and towards the people with whom we have sex,” explains Bastian, a sexual rights activist. In the his speech at the thirteenth edition of the Italian Conference on AIDS and Antiviral Research. Yet, four years after the introduction of this drug in Italy, «the information work is entrusted to the people who are on Grindr instead of being carried out by the institutions assigned to prevention. I think that leaving all this work to us, as if it were a clandestine thing or “for the few”, is a form of stigmatization on the part of the national health service “, adds Mirco. For this reason and to ask for the reimbursement of PrEP, a group of associations led by PrEP in Italy and PLUS have organized a sit-in in Rome, in front of the headquarters of the Ministry of Health.
“PrEP shows the elephant in the room, meaning that not all people use condoms, despite thirty years of campaigning on the subject,” Bastian points out in his testimony. And the motivations of those who use PrEP are all very personal and different from each other: “People who have never used the condom, people who use it sometimes, people who experience sexuality with a condom badly and to whom PrEP can return a full and satisfying sex life ”, explains Calzavara. And not only that: PrEP is also useful for those who do sex work, for those who live in an abusive relationship and cannot ask their partner to use the condom, for women and people with vulva (who, however, can only take PrEP continuously in case of receptive vaginal intercourse). “PrEP is not just a drug, nor a health protocol: PrEP is empowerment,” sums up Bastian. “It allowed me to have a free and conscious sex life, it taught me to be honest with myself and to admit that I can have risky behaviors, but I don’t have to feel guilty because using it I protect myself from HIV and reduce the harm monitoring the transmission of other sexually transmitted infections’.
For him and for many other people in Italy, the future is a place where “PrEP has the same dignity as condoms. A future where the important thing will not be to tell people how to have sex, but to provide all the prevention tools that medicine makes available to us today “.
Preview image: NIAID, CC BY 2.0, via Wikimedia Commons