Opinion: 3 questions for rolling out the next generation of HIV prevention

By Neeraja Bhavaraju 01 December 2016

Health workers at an HPV vaccination program in Sao Paulo, Brazil. Photo by: Pan American Health Organization / CC BY-ND

Hope that we can end the HIV epidemic in our lifetime is moving closer with the introduction of oral pre-exposure prophylaxis and other new innovations. These products offer incredible protection alongside the traditional methods of condom use and behavior change for those who are HIV negative. They are revolutionary for women and girls, who are at growing risk for HIV infection and have never had a prevention method that they could control.

Still, the development of PrEP products is just the beginning. How can we accelerate the introduction of these products to the people who need them most?

The history of health is filled with examples of lifesaving innovations that scale up quickly in commercial markets but lag for decades in less lucrative markets. With new HIV prevention products, we must do better. We need political systems that prioritize HIV prevention; health systems that are organized to reach populations in need; and individuals who are aware of available options, understand their benefits, and actually want to use them.

Building a comprehensive product introduction system is challenging, even in well-resourced countries. The HPV vaccine, for example, is highly effective in reducing the risk of cervical cancer for women, yet nearly 10 years after the product’s regulatory approval, only 60 percent of young women in the United States and 1 percent of vaccine recipients come from low- and middle-income countries.

To accelerate this trajectory for oral PrEP, we need to tackle some critical questions:

1. How should resource-constrained ministries of health allocate resources?

New HIV prevention methods offer enough promise that several governments in sub-Saharan Africa are planning to introduce them in public health systems. But this is an expensive proposition, especially with other concurrent needs: to invest in universal HIV testing and treatment and expand existing, effective HIV prevention measures such as condom distribution and male circumcision, which are often more cost-effective in the short term. Given these considerations, how can a country choose between prevention and treatment?

Ministries of health have increasingly turned to data to answer this question, conducting cost-effectiveness analyses to identify interventions that provide the biggest health impact per dollar. A rights-based assessment is also critical. For example, if girls and young women are unable to advocate for safer sex practices or condom use, the health system should offer them an HIV prevention option that they can use to protect themselves — even if that option is more expensive in the short term.

2. How does the health system effectively and consistently reach healthy people?

With new options, the immediate temptation is to manage and deliver new products within the HIV system, through HIV clinics or testing sites. While this may be the most convenient or even the cheapest option, it is likely to prove ineffective. Healthy people do not want to go to HIV clinics and do not want to take pills that look like those used to treat HIV. “I’m not sick,” one young woman noted at AIDS 2016 in Durban “so it feels strange to take a pill every day.” To effectively deliver new HIV prevention products, governments will need to look outside their current systems of HIV care — to family planning clinics, for example, or even to school-based clinics as is done with vaccines — to reach potential users. Community and NGO programs will also be important, as will new mobile phone technologies to support user uptake and adherence.

3. How do we mitigate bias and stigma in the health system?

Plans often focus on growing a country’s cadres of doctors, nurses, and others who can deliver health care, on expanding laboratory capacity for testing and diagnosis, or on establishing electronic medical records and improved monitoring and surveillance. While all of these are critically important, they often mask one of the biggest challenges in health care delivery: the attitudes and beliefs of health care workers themselves.

“If I go into the clinic asking for this [oral PrEP], it will be like an interrogation,” shared another young woman at AIDS 2016. Providers are critical gatekeepers to populations in need. This has proven to be one of the greatest challenges in the introduction of the HPV vaccine and is evident even in the earliest days of oral PrEP introduction.

We need to struggle with these difficult questions to get the best results. As part of the OPTIONS Consortium, we are working with groups in South Africa, Kenya, and Zimbabwe, to help decision-makers develop a comprehensive, system-based approach for oral PrEP introduction and to highlight what works to get these new options in the hands of those who need them. This was the focus of my panel discussion on “Improving quality of HIV and TB Care” at the Fourth Global Symposium for Health Systems Research, in Vancouver, Canada.

Without a systems approach to product introduction, including data collection to inform decision-making, innovative approaches to health care delivery and support for health care workers and community engagement, our new HIV prevention options will not reach the people who need them most. And that is simply not an option this time around.

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About the author

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Neeraja Bhavaraju

At FSG, Neeraja Bhavaraju leads projects across sectors to address challenges such as access to HIV prevention for women and girls in sub-Saharan Africa, and financial inclusion in developed and developing markets. Neeraja has also worked to strengthen partnerships such as the EYElliance, a consortium of actors seeking to improve access to eye care and eyeglasses, and the USAID-funded OPTIONS Consortium, whose goal is to accelerate the market introduction and scale-up of female-controlled HIV prevention technologies.


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