Will pill reduce infections?
of treatment for all people living with HIV and PrEP for those at substantial risk, many countries are including both recommendations in their national adaptations.
But this doesn’t imply countries have clear plans or funding to deliver PrEP yet. Although several countries have PrEP in their ARV guidelines, far fewer have developed PrEP guidance — the more detailed, interventionspecific roadmap for deciding who should get PrEP, what tests and counselling messages should go with it and how doctors should approach the ongoing health monitoring and support for people who are taking it. To adopt PrEP into national guidelines without then moving onward to specific guidance that identifies how best to deliver the strategy to populations who need it would be a huge error.
Some countries have made progress with this. In July, Kenya launched its new guidelines on the use of ARVs for treatment and prevention with oral PrEP, in the form of pills, fully integrated. Although PrEP is not yet included in the current South African ARV guidelines, it is enshrined in the country’s response in a number of ways, including approval in 2015 by the Medicines Control Council for Truvada to be used for PrEP.
PrEP has also been included in the health department’s national strategic plan for HIV, sexually transmitted infections and tuberculosis, and the Southern African HIV Clinicians Society published expanded PrEP guidelines in early 2016.
From guidance, we need to move to programmes. This is where we will gain invaluable information about how, and for whom, PrEP will work in the real world.
In June, South Africa formally launched its national PrEP programme at a number of clinics that serve sex workers.
But we need to remember: oral PrEP, in the form of an HIV prevention pill, is a new option. It hasn’t been delivered at national scale any- where in the world.
Even in the United States, where PrEP was approved over four years ago, large-scale programmes, marketing campaigns and broad access are only just beginning. We’re still in the learning stage — figuring out how to deliver counselling messages that support choice and that help people stay on PrEP, especially those at greatest risk.
We must ensure gender equity in access: getting PrEP to women who are old, young, pregnant or using contraceptives, gay men and other men who have sex with men, and to transgender women.
We are also aware of the dangers. And there are many. Chief among them is that PrEP could be launched in a way that dooms it to fail. Public health history is littered with examples of innovations that didn’t reach the people who needed them most,in a timely and effective manner.
The hepatitis B vaccine was originally targeted at specific populations who were already stigmatised, so the vaccine also became stigmatised.
The female condom was introduced without supportive programming in most countries — and then, when women didn’t embrace it, the public health establishment largely declared that it had failed. The list goes on and on. So now, before it is too late, we must chart a course that avoids these pitfalls. We must, first and foremost, move with speed.
A fascinating session with current PrEP users and programme implementers at the recent Aids 2016 conference in Durban showed how much we are already learning from current PrEP programmes.
The take-home message from that session was clear: “PrEP is not perfect. It is not easy. It is not for everyone. It is not for always. It will not end HIV — or, of course, the underlying social and structural issues — on its own. But we won’t end the epidemic without it.”