One pill a day can prevent HIV: Why are we not providing it in most MSF projects?
There is no doubt that oral pre-exposure prophylaxis (PREP), i.e. use of the combination TDF+FTC antiretroviral daily, can prevent HIV infection. In fact, it is the ONLY realistic tool for women to protect themselves from becoming infected with HIV, since it is confidential and not dependent on the male partner. So why are we not yet using it in most of our projects or fighting for access to it?
I attended a meeting of partners involved in ongoing or planned PrEP demonstration projects in 10 African countries, together with Ruggiero, Medical Coordinator in Mozambique. The main message from this meeting is that we need to implement PrEP more widely and outside of research contexts.
The latest WHO guidelines (Sept 2015 version available here) strongly endorse implementation of oral PrEP for risk groups with HIV incidence of ~3% per year or more.
In addition to sex workers and men who have sex with men (MSM), young women in high HIV prevalence settings and partners of HIV-positive people may also have such high risk.
For MSM and sex workers, a PREP intervention may be applied to the entire population; but amongst adolescent girls and young women, it may be more difficult to justify routine promotion of PrEP for all. We will need to develop context-specific health promotion and delivery strategies to identify those at risk and offer PrEP appropriately, especially where cultural issues stigmatize risk behaviour.
A few points from the meeting worth highlighting include:
– There is little evidence yet on how well PrEP works in ‘real world settings’ in Africa. A major doubt exists whether people at risk of becoming infected with HIV will accept PrEP and whether they will take preventive antiretroviral medication when they have access to it. These are especially important questions for any MSF projects considering implementation of PrEP.
– Most participants in the meeting felt that PrEP will work better in reality than in studies, providing it is offered to people who self-identify as ‘at risk’. Such people are more likely to be motivated to adhere to PrEP and good adherence is essential for PrEP to be effective. Remember that people only need to take PrEP for the periods of their lives when they are at risk and it is perfectly acceptable that a person use it for some months, then stop using it and then restart.
– PrEP guidelines mention either tenofovir (TDF) alone or the combination of tenofovir + emtricitabine (FTC) as antiretroviral medication to use. They do not mention the combination of TDF + lamivudine (3TC), which is commonly available in resource-limited settings. There is a push to include TDF + 3TC in PrEP interventions, since it is quite accessible and will almost certainly work just as well.
– While the main objective of PrEP is to prevent HIV, it is worth noting that PrEP requires HIV testing at initiation and at least every 3 months (since it can only be continued among people who test negative regularly). Perhaps the benefit of incentivizing regular HIV testing (and hence early treatment) could be as important as its benefit in reducing infection.
For additional information about implementation of PrEP, including its pros and cons, please take a look at the PrEP Watch website, which has done a great job of collating work related to PrEP and offering materials for sharing. Tools for promotion of PrEP in communities are available at related weblinks (http://women.prepfacts.org/ and www.whatisprep.org). Although these may not necessarily be adaptable to all of our settings, they can get us thinking and give a good headstart!
We hope that MSF projects with high risk populations will take up this challenge. SAMU is ready to provide support to those that do. Support could include advising on how to get agreement from Ministries of Health (MoH), design and writing of project proposals, promotion of PrEP within communities, and development of standardized and simplified tools and forms for monitoring and evaluation (M&E).
PrEP activities in the MSF Belgian project in Mozambique have taken over 2 years to get off the ground; lessons learned and tools developed will hopefully help other projects to move much faster.
Please e-mail us or contact your SAMU focal point for more information…