PrEP implementation research in Africa: what is new?

Abstract

IntroductionOf the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings.DiscussionIn each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.ConclusionsEfficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.

Interest in HIV pre‐exposure prophylaxis in men who have sex with men in West Africa (CohMSM ANRS 12324 – Expertise France)

“…Despite these developments, the data about the acceptability of PrEP in MSM in sub‐Saharan Africa are scarce, especially in West Africa where no studies have yet been conducted . Implementing PrEP in MSM in West Africa is crucial given their vulnerability to HIV infection and the high risk of transmission to the general population .…”

Changes in engagement in HIV prevention and care services among female sex workers during intensified community mobilization in 3 sites in Zimbabwe, 2011 to 2015

“…Uptake of preventive behaviours such as reported condom use with clients did not improve as anticipated by the intensified services. Programmes will need to better link HIV‐negative FSWs to prevention services including PrEP as part of a combination prevention strategy .…”

Women’s estimated HIV infections from sex in trials of pre-exposure prophylaxis in Africa: Implications for HIV prevention strategies

“…[50] The case for warning people about bloodborne risks is based not only on the potential for warnings to reduce HIV incidence but also on ethics. The World Medical Association's Declaration of Lisbon [51] avers (principle 9): "Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services…" Implications for prevention: Reconsider oral PrEP for women in Africa: Both UNAIDS and the World Health Organization (WHO) along with demonstration projects [52] propose extending oral PrEP in Africa to women in the general population who are at high risk (ie, in communities where HIV incidence in young women is >3 per 100 PYs).…”