Barriers to PrEP: Rollout of this HIV prevention tool is hitting bumps

For Ben Brown, taking an extra pill with his daily vitamins which provides him protection against HIV is worth its weight in gold.

“I don’t even think about HIV. I’m protected,” he told Devex at the 2016 International AIDS Conference in Durban, South Africa.

Pre-exposure prophylaxis, or PrEP, is the use of antiretroviral medication to prevent the acquisition of HIV infection by uninfected people. In 2014, the World Health Organization recommended offering PrEP to men who have sex with men — known as MSM — and in September broadened its recommendation to include all people at substantial risk of HIV infection as an additional prevention choice.

“It’s not just for those having risky sex, it’s about taking control of your own life,” Brown said. “People ask, ‘why can’t you use condoms?’ [but] condoms fail, in so many situations they don’t work. PrEP works well in filling in the gaps.”

Brown is a senior technical consultant and researcher from the Anova Health Institute based in Cape Town, which in 2008 launched a project called Health4Men to take the lead in South Africa’s response to HIV among gay, bisexual and other men who have sex with men.

The organization supports MSM-competent sexual health clinics in all nine South African provinces with centers of excellence in Cape Town and Johannesburg, both which offer PrEP.

Brown said that once an MSM reaches one of their PrEP demonstration sites, accessing the drug “couldn’t be simpler,” with nurses offering counseling and support to those who are interested.

“PrEP isn’t for everyone but it is for a lot of people,” said Brown. “[However], a lot of awareness-raising needs to be done. People are not great at understanding their risk.”

Last year, South Africa’s Medicines Control Council approved PrEP and in June this year the government began rolling it out among selected sex worker programs around the country. There are hopes it will be rolled out in the public sector by the end of the year.

Health care delivery systems must be fixed

Keletso Makofane from the Global Forum on MSM and HIV said that while the prevention tool was encouraging, it would have no impact unless the health care delivery systems responsible for delivering PrEP were fixed.

Staff shortages, frequent stockouts, treatment oversights and stigma within clinics and the community were some of the issues he listed.

“If that’s the system we depend on to deliver PrEP then the intervention won’t work,” Makofane said.

But of course an intervention can only work if people have access to it.

Currently there are demonstration programs being rolled out in 20 countries including eight countries in sub-Saharan Africa, according to PrEP Watch.

PrEP Watch is an initiative of AVAC, a nongovernmental organization based in New York that works to accelerate the ethical development and global delivery of new and emerging HIV prevention tools.

Meanwhile, Truvada — the PrEP drug manufactured by Gilead Sciences — has been registered for use in more than 100 countries.

UNAIDS Executive Director Michele Sidibé said the agency was working with countries to try and introduce PrEP. He added it was also trying to engage with Eastern Europe and Central Asia — regions where the AIDS epidemic is on the increase — to encourage countries to have appropriate policy reform, particularly for people who inject drugs.

“If you cannot come for services, you cannot get the pill,” he said. “If you have a series of bad laws that are not removed, [PrEP] will be impossible for us to implement because the impact will be little.”

Dr. Rachel Baggaley from the WHO’s HIV department said in countries where PrEP was being rolled out, programs had to be evaluated to show health ministries that it was working and that it was effective.

Increasing access for young women

Nomtika Mjwana from the Sexual and Reproductive Justice Coalition in South Africa echoed Sidibé’s thoughts. She said the biggest issue for PrEP was its accessibility, particularly for girls and women who in sub-Saharan Africa make up 71 percent of new infections among adolescents.  

Health care systems across the region had to examine how they cater to young women, she said, if PrEP was going to be successfully rolled out.  

“PrEP is amazing and empowering but what support structures are there? What communication is there? And what language is being used to actually address the fact that young women need these services?”

But while experts are excited about the potential PrEP holds to prevent new HIV infections, there are major concerns about its potential scale-up given funding for the response is declining.

New data published by the Kaiser Family Foundation and UNAIDS shows for the first time in five years, in 2015, 13 of 14 donor governments that provide the bulk of international assistance for AIDS through bilateral programs and contributions to the Global Fund reduced their funding for low- and middle-income countries.

Dr. Chris Beyrer, Desmond M. Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, said he was extremely concerned for key populations such as MSM because host countries were less likely to fund HIV programs for such groups, even though they would greatly benefit from PrEP.

“This a very real concern. Key populations are more threatened than anyone else with the decline in dollars,” he said.

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