HIV: PrEP prevents infection, but uptake is still too low

When taken every day consistently, pre-exposure prophylaxis has been shown to reduce new infections by 95 per cent.

The oral anti-retroviral drug Truvada, which is a combination of tenofovir and emtricitabine, was approved for use as pre-exposure prophylaxis (PrEP) in Kenya in April 2017.

Moreover, guidelines for the use of antiretroviral drugs for the treatment and prevention of HIV infection, were launched, recommending immediate initiation of PrEP for everyone who is has a substantial ongoing risk of being infected with HIV.

However, lack of drugs in public hospitals, lack of awareness, health worker attitude, treatment oversights and stigma in clinics and in the community is hindering the uptake of PrEP in Kenya and other countries.

A study done in 10 counties (Kisumu, Migori, Kisii, Nairobi, Machakos, Kiambu, Mombasa, Kilifi, Kwale and Taita Taveta) revealed that there was a huge gap between participants who were screened and found eligible for PrEP, and those who were actually put on the preventive therapy.

The gap was due in part to the stigma associated with the clinic offering PrEP services, and also because health workers counselled young girls who needed PrEP out of it.

he study enrolled 8,000 female sex workers and 2,400 men who have sex with men.

According to Dr Linda Gail Bekker, the deputy director of Desmond Tutu HIV Foundation in South Africa, PrEP uptake is still slow because most countries are not making people aware of it.

"People are not aware of it. We have not gone out and shouted about it in schools and clinics. Countries fear that they would be overwhelmed by the number of people on the drug. If we do not have a full scale demand creation strategy, then it has to go by a word of mouth, which is a slower method,” she said, adding that a mass campaign was necessary to tell everyone that PrEP works.

NOT FOR EVERYONE

She added that people do not know about the drug, how it works, which groups can benefit from it, and where the drug can be accessed.

“PrEP is not for everyone, but it is for a lot of people. There needs to be a lot of awareness creation because people are not good at understanding their risk. These barriers keep people away from treatment. For prevention, we have to make it easier for people to access the drug,” she told Healthy Nation at a recent HIV conference.

According to data from PrEP Watch, there are 26,000 estimated users of PrEP in Kenya, against a target of 37,000 from all ongoing and planned projects.

Globally, there are 309,525 people on the drug in 68 countries, though majority of the users (71 per cent) are in North America.

In sub-Saharan countries, 49,000 people (mostly adolescent girls and young women) are on PrEP, against a target of 141,754 users.

Most PrEP users in Africa are in Kenya, South Africa, Uganda, Zimbabwe and Lesotho.

NEW INFECTIONS

Globally, the populations most frequently put on PrEP regimens are men who have sex with men, adolescent girls and young women, female sex workers and discordant couples (where one partner is HIV-positive, while the other is not).

According to Dr Nelly Mugo, the principal research scientist at the Kenya Medical Research Institute and the principal researcher on the PrEP efficacy trials conducted in Kenya, while not everyone can be on PrEP, it can only work if people have access to it. In Kenya, the drug is only available on prescription.

“If a non-infected person takes PrEP, then the virus is killed if it enters their body. This means it doesn’t have a chance to hide in reservoirs, and so it is harder for that person to become infected,” explained Dr Mugo.

She added that the prevention tool had been proven to be effective, but it would have no impact unless the healthcare delivery systems for delivering PrEP are fixed.

“Why would a health worker talk a young girl who is sexually active out of taking the drug? Why would those eligible for the drug not access it? Why would policy makers be against PrEP? Why are the drugs not available in hospitals where most people frequent?” posed Dr Mugo, calling for an overhaul of the PrEP delivery system if the intervention is to help prevent new HIV infections.

“The problem is most governments do not consider demand creation as a public health decision. We need to push so that action is taken,” she said.

PrEP was first approved for use by the Food and Drug Administration of the United States in 2012.

Two years later, the World Health Organisation recommended offering PrEP to men who have sex with men and later broadened its recommendation to include all people at substantial risk of HIV infection as an additional option to prevent HIV infection.

The Kenya Pharmacy and Poisons Board approved the use of oral PrEP in December 2015.