Transforming HIV prevention in Europe

This article is part of POLITICO Telescope: The New AIDS Epidemic, an ongoing exploration of the disease today.

The world’s battle to end the HIV epidemic is being fought on two fronts. The first involves getting as many people as possible who are living with the virus diagnosed and rapidly onto antiretroviral medication. This reduces the virus inside their bodies to such a low level that it is undetectable and therefore cannot be passed to others. The approach is known as “undetectable = untransmittable” or “U=U*.”

The second front is focused on protecting people from contracting the virus in the first place, even if they have been exposed to it — an approach known as pre-exposure prophylaxis, or PrEP. Taken as prescribed, PrEP makes a person’s body almost entirely resistant to HIV infection.

There is a critical need to bring forward new PrEP options that are informed by and designed for the communities that could benefit from PrEP in Europe.

Jared Baeten MD, PhD, vice president for HIV clinical development at Gilead Sciences

PrEP comprises antiretroviral drugs that can be taken intermittently, around the time someone expects to be sexually active. They protect against the virus in two ways: by increasing the production of antibodies in the cells in the rectal or vaginal lining, making them less receptive to HIV in the first place, and by interfering with the ability of HIV to replicate in the body.

Nearly 5 million people around the world have taken PrEP at least once — including about 2.8 million in Europe — and it has been shown to reduce the incidence of HIV infection during sex by 99 percent. In the European Union, new HIV infections have fallen by about 45 percent since PrEP was licensed in 2016, although this decline is also partly due to U=U.

PrEP as part of combination prevention strategies

Missing doses or running out of PrEP can mean becoming susceptible to HIV again. I via Shutterstock

Today, PrEP comes primarily in the form of an oral tablet, which has the advantage of being cheap to produce and easy to store. But it is not a universal solution. Because it needs to be taken regularly while someone is sexually active, missing doses or running out can mean becoming susceptible to HIV again. What’s more, in the same way that some bacteria are developing resistance to antibiotics, the HIV that does enter the bodies of people who have paused or discontinued their use of PrEP has a greater chance of being resistant to subsequent antiretroviral medications they may then need.

PrEP taken in tablet form is also an issue for people who need to keep their use of PrEP private, perhaps from family members or partners. Having to take a pill once a day or two or three times a week is something that may be hard to hide from others. And some people, such as migrants, who may not be fully integrated with a country’s health care system, may find it hard to access regular supplies of daily medication. Limitations such as these have prompted the development of alternative, innovative ways for people to protect themselves that are more tailored to their needs and life situations. These include longer-acting drugs that can be injected.

Like existing oral medications, injectable PrEP works by preventing HIV from replicating in a person’s body, but its effect lasts much longer. In September, the EU approved the use of the first intramuscular injectable that can be given every two months. Gilead is, until 2027, running trials of another injectable option, which, once the required efficacy and safety have been demonstrated, could be administered subcutaneously just once every six months. This would be more convenient for many people and more adapted to the circumstances of certain populations, such as migrants, and may therefore lead to better adherence and health outcomes.

HIV continues to be a public health threat across Europe, where in 2022 more than 100,000 people were newly diagnosed with HIV.

Jared Baeten MD, PhD, vice president for HIV Clinical Development at Gilead Sciences

Further ahead — but still in the early stages of development and testing — are patches and implants, which would provide a continuous supply of antiretroviral drugs, and immunotherapies. Immunotherapies would comprise a broad spectrum of naturally produced or manufactured antibodies against HIV, which, in theory, would pre-arm their bodies to resist infection.

As more types of PrEP become available, we will see a greater awareness of its benefits, as more people are able to find the version of PrEP that best suits their living conditions and personal requirements. This is a fundamental principle of “combination prevention,” or innovative interventions that reflect the specific needs of the people they are trying to reach.

Preparing for the future

Despite clear scientific evidence of the benefits of PrEP, there are still some hurdles we need to overcome to make it a powerful tool to end HIV altogether. These include investments and funding in prevention and availability, and programs to combat stigma.

Although the EU licensed PrEP in 2016, availability varies across the bloc. In France, the U.K., Spain, Germany and, more recently, Italy, oral PrEP is available at no cost to those who would benefit from it. In Romania, although PrEP is included in the country’s new HIV National Strategy, it is not yet funded, and it is only available via non-governmental organizations that rely on external funding sources. And in Poland, Hungary and Bulgaria, PrEP is not state funded and there are no current plans to make it so. In many member states, even though PrEP is technically licensed, in practice it can be hard to get hold of, in particular for specific communities, such as women, migrants or trans people. Potential users may find it hard, for example, to access testing or even doctors who are willing to prescribe it.

Jared Baeten MD, PhD, vice president for HIV clinical development at Gilead Sciences

Another key challenge that health systems and providers face is communicating the importance of PrEP to those who would most benefit, and thereby increase uptake. Many respondents in multiple studies have indicated that they don’t feel HIV is something that affects them, or they have indicated that there is a general stigma in their communities associated with sexual health matters. And some groups that are already discriminated against, such as sex workers, people who inject drugs, and migrants, may be hesitant to engage with health care systems for fear of reprisals. Again, injectable PrEP could help reach such key populations as it will offer a more discreet way of accessing the preventive treatment.

“There is a critical need to bring forward new PrEP options that are informed by and designed for the communities that could benefit from PrEP in Europe,” says Jared Baeten MD, PhD, vice president for HIV clinical development at Gilead Sciences. “At Gilead, we are excited to engage with communities and broader stakeholders to inform our trials efforts and partner with them in our goal to develop person-centered innovations that can help end the HIV epidemic in Europe.”

Europe is leading the world’s efforts toward ending HIV, but, even in the bloc, PrEP usage and availability varies from country to country and demographic to demographic. If the region is to become the first to end the HIV epidemic entirely, the European Commission, the European Parliament and the governments of member states will need to lead the way in fighting stigma, promoting and prioritizing HIV prevention in all its aspects including innovation in therapeutics strengthening the financing and funding of healthcare systems, and establishing effective pathways to zero transmission to end HIV entirely.

“HIV continues to be a public health threat across Europe, where in 2022 more than 100,000 people were newly diagnosed with HIV,” says Baeten. “HIV prevention is critical and has the potential to change the trajectory of the epidemic, but stigma and other barriers limit the impact that PrEP medications can have on reducing HIV infections in Europe. We all have a responsibility to collaboratively partner to make this work.”

*U=U is true on two premises: taking HIV medicines as prescribed and getting to and staying undetectable for at least six months prevents transmitting HIV to partners through sex. Undetectable means that the virus cannot be measured by a viral load test (viral load <200 copies/mL)



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Turkish century: History looms large on election day

ISTANBUL — From the Aegean coast to the mountainous frontier with Iran, millions of Turks are voting at the country’s 191,884 ballot boxes on Sunday — with both President Recep Tayyip Erdoğan and his main rival Kemal Kılıçdaroğlu warning the country is at a historical turning point.

In the last sprints of the nail-bitingly close election race, the dueling candidates have both placed heavy emphasis on the historical resonance of the vote falling exactly 100 years after the foundation of the secular Turkish republic by Mustafa Kemal Atatürk in 1923.

In the Istanbul district of Ümraniye on the final day of campaigning, Erdoğan told voters the country was on “the threshold of a Turkish century” that will be the “century of our children, our youth, our women.”

Erdoğan’s talk of a Turkish century is partly a pledge to make the country stronger and more technologically independent, particularly in the defense sector. Over the past months, the president has been quick to associate himself with the domestically-manufactured Togg electric car, the “Kaan” fighter jet and Anadolu, the country’s first aircraft carrier.

But Erdoğan’s Turkish century is about more than home-grown planes and ships. Few people doubt the president sees 2023 as a key threshold to accelerate his push away from Atatürk’s secular legacy and toward a more religiously conservative nation. Indeed, his campaign has been characterized by a heavy emphasis on family values and bitter rhetoric against the LGBTQ+ community. Unsurprisingly, he wrapped up his campaign on Saturday night in Hagia Sophia — once Constantinople’s greatest church — which he contentiously reconverted from a museum back into a mosque, as it had been in Ottoman times.    

The state that Atatürk forged from the ashes of the Ottoman empire in 1923 was secular and modernizing, often along Western models, with the introduction of Latin letters and even the banning of the fez in favor of Western-style hats. In this regard, the Islamist populist Erdoğan is a world away from the ballroom-dancing, rakı-quaffing field marshal Atatürk.

The 2023 election is widely being cast as a decisive referendum on which vision for Turkey will win through, and Erdoğan has been keen to portray the opposition as sell-outs to the West and global financial institutions such as the International Monetary Fund. “Are you ready to bury at the ballot box those who promised to give over the country’s values ​​to foreigners and loan sharks?” he called out to the crowd in Ümraniye.

This is not a man who is casting himself as the West’s ally. Resisting pressure that Ankara should not cozy up so much to the Kremlin, Erdoğan snapped on Friday that he would “not accept” the opposition’s attacks on Russian President Vladimir Putin — after Kılıçdaroğlu complained of Russian meddling in the election.   

All about Atatürk

By contrast, Erdogan’s main rival Kılıçdaroğlu is trying to assume the full mantle of Atatürk, and is stressing the need to put the country back on the path toward European democratic norms after Erdoğan’s lurch toward authoritarianism. While Erdoğan ended his campaign in the great mosque of Hagia Sophia, Kılıçdaroğlu did so by laying flowers at Atatürk’s mausoleum.

Speaking from a rain-swept stage in Ankara on Friday night, the 74-year-old bureaucrat declared: “We will make all of Turkey Mustafa Kemal’s [Atatürk’s] Turkey!”

In his speech, he slammed Erdoğan for giving Turkey over to drug runners and crony networks of oligarch construction bosses, saying the country had no place for “robbers.” Symbolically, he chided the president for ruling from his 1,150-room presidential complex — dubbed the Saray or palace — and said that he would rule from the more modest Çankaya mansion that Atatürk used for his presidency.

Warming to his theme of Turkey’s “second century,” Kılıçdaroğlu posted a video in the early hours of Saturday morning, urging young people to fully embrace the founding father’s vision. After all, he hails from the CHP party that Atatürk founded.

“We are entering the second century, young ones. And now we have a new generation, we have you. We have to decide altogether: Will we be among those who only commemorate Atatürk — like in the first century — or those who understand him in this century? This generation will be of those who understand,” he said, speaking in his trademark grandfatherly tone from his book-lined study.

At least in the upscale neighborhood of Beşiktaş, on Saturday night, all the talk of Atatürk was no dry history lesson. Over their final beers — before an alcohol sale ban comes in force over election day — young Turks punched the air and chanted along with a stirring anthem: “Long Live Mustafa Kemal Pasha, long may he live.”

In diametric opposition to Erdoğan, who has detained opponents and exerts heavy influence over the judiciary and the media, Kılıçdaroğlu is insisting that he will push Turkey to adopt the kind of reforms needed to move toward EU membership.

When asked by POLITICO whether that could backfire because some hostile EU countries would always block Turkish membership, he said the reforms themselves were the most important element for Turkey’s future.

“It does not matter whether the EU takes us in or not. What matters is bringing all the democratic standards that the EU foresees to our country,” he said in an exclusive interview on the sidelines of a rally in the central city of Sivas. “We are part of Western civilization. So the EU may accept us or not, but we will bring those democratic standards. The EU needs Turkey.”

Off to the polls

Polling stations — which are set up in schools — open at 8 a.m. on election day and close at 5 p.m. At 9 p.m. media can start reporting, and unofficial results are expected to start trickling in around midnight.

The mood is cautious, with rumors swirling that internet use could be restricted or there could be trouble on the streets if there are disputes over the result.

The fears of some kind of trouble have only grown after reports of potential military or governmental involvement in the voting process.

Two days before the election, the CHP accused Interior Minister Süleyman Soylu of preparing election manipulation. The main opposition party said Soylu had called on governors to seek army support on election night. Soylu made no public response.  

Turkey’s Supreme Election Council (YSK) has rejected the interior ministry’s request to collect and store election results on its own database. The YSK also banned the police and gendarmerie from collecting election results. 

Erdoğan himself sought to downplay any fears of a stolen election. In front of a studio audience of young people on Friday, he dismissed as “ridiculous” the suggestion that he might not leave office if he lost. “We came to power in Turkey by democratic means and by the courtesy of people. If they make a different decision whatever the democracy requires we will do it,” said the president, looking unusually gaunt, perhaps still knocked back by what his party said was a bout of gastroenteritis during the campaign.

The opposition is vowing to keep close tabs on all of the polling stations to try to prevent any fraud.

In Esenyurt Cumhuriyet Square, in the European part of Istanbul, a group of high-school students gathered on Saturday morning to greet Ekrem İmamoğlu, the popular mayor of Istanbul, who would be one of Kılıçdaroğlu’s vice presidents if he were to win.

Ilayda, 18, said she would vote for the opposition because of its position on democracy, justice and women’s rights.

When asked what would happen if Erdoğan won, she replied: “We plan to start a deep mourning. Our country as we know it will not be there anymore.”



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