The armoury of HIV prevention
Several important questions that still need to be public health sector. By
experience with the HIV prevention pill, the public health sector could begin offering the shot in as little as three to six months after national guidelines are finalised.
That is, if South Africa can afford it. In the US, the injection’s official price tag can be as high as R391,000 per patient per year. ViiV Healthcare has agreed to allow at least three producers of generic medicines to provide affordable versions of the injection to low- and middle-income countries as well as countries in sub-Saharan Africa.
However, it could take as long as five years for generic versions to be ready for distribution. Until then, the company has committed to affordable pricing for countries like South Africa, but it declined to publicly confirm to Spotlight what price it will charge in South Africa.
Research recently published in The Lancet medical journal found that for the HIV prevention injection to be cost-effective in South Africa, it should cost no more than R1,800 per person per year. ViiV Healthcare previously told Spotlight that the price is unrealistic.
Delivery dilemmas
For a decade, South Africa has invested heavily in moving HIV prevention and care out of hospitals and clinics and closer to communities. Providing medicine closer to home, research shows, often makes it more convenient for people and helps decongest busy clinics.
You can get three-month supplies of the HIV prevention pill via courier, mobile clinics or even fast-tracked queues at clinics, depending on where you live. Many of these services are provided by NGOs.
But figuring out how to provide the HIV prevention shot every other month outside of health facilities is tricky, admits Desmond Tutu Health Foundation COO Dr Linda-Gail Bekker.
“That is one of the biggest implementation science questions that we need to answer, and quickly,” she said. “I can send pills by courier, but I can’t do that with a bottle of cabotegravir. Suddenly, now you need a nurse who is specially trained to give an injection, which needs privacy – albeit only every two months. But still, for that you need infrastructure.”
Bekker says the foundation will be looking at piloting the injection in community
“shot clinics”, using simple trailers staffed by a nurse and counsellor. Patients coming in for injections every two months could also get contraception, treatment for sexually transmitted infections, or other routine vaccinations like that for the human papillomavirus, which is linked to some forms of cervical cancer.
Meanwhile, research institute Ezintsha hopes to pilot the jab in Clicks pharmacies. Wits RHI says it will offer the shot in its mobile clinics and the public facilities it already supports. Ezintsha and Wits RHI confirmed that both pilots are slated to offer all three forms of PrEP – the shot, the pill and the vaginal ring.
At least initially, pharmacists and nurses already trained to initiate and manage patients on antiretrovirals, including PrEP, will likely be tasked with administering the shot. In the case of nurses, these scarce healthcare workers are often known as Nimart nurses, which is short for nurseinitiated management of antiretroviral treatment. These nurses, along with doctors and specially trained pharmacists, already start and manage patients on the HIV prevention pill.
But relying on Nimart nurses to provide oral PrEP has limited the HIV prevention pill’s availability and integration into other health services, wrote Bekker and other experts in July in The Lancet.
In the past six years, only about 569,977 people in South Africa have ever started on the HIV prevention pill, according to data collected by the Aids Vaccine Advocacy Coalition.
Experts generally agree that the HIV prevention injection will – like oral PrEP – need to be provided alongside other sexual and reproductive health services. But Bekker says the injection may push researchers and health officials to get even more creative with how they bring the shot closer to communities.
“We might have to come up with a new array of … service delivery models,” she said.
About more than numbers
In the past decade, the world has seen the debut of a pill, a ring and now an injection that can slash people’s risk of HIV infection.
That is one of the biggest implementation science questions that we need to
answer and quickly … I can send pills by courier, but I can’t do that with a
bottle of cabotegravir
All three are effective at preventing infection. Still, they performed differently in clinical trials. The HIV injection technically outperformed the pill in trials because it was easier to take than a daily tablet. In clinical trials, the vaginal ring still cut women’s HIV risk by about a third. And although the ring resulted in even bigger reductions in HIV risk in the real world, poorer than expected clinical trial results seemed to dampen donors’ appetite to fund the technology, albeit temporarily, some advocates say.
But effectiveness is not the only thing that drives people’s decision to start PrEP or their choice in type of PrEP, says Dr Saiqa Mullick, director of implementation science at Wits RHI. Hope is a bigger factor than fear. “Empowering messaging works, and that’s a big thing,” said Mallick.
This article first appeared in Spotlight.