ARE YOU PrEPPED?
Pre-exposure prophylaxis (PrEP) is being rolled out to protect those at high risk of HIV infection – yet to date, few heterosexual women have considered it. Depending on your lifestyle (or your partner’s), perhaps you should…
The revolutionary HIV preventative EVERYONE should know about
AS someone who works in the health sector and prides herself on taking responsibility for her own health and that of her family, 37-year-old Cheryl* couldn’t believe it when a routine HIV test for an insurance company came back positive. ‘I’ve been pretty comfortably married for 12 years and I’ve never touched a drug that wasn’t prescribed,’ she says. ‘I couldn’t get my head around it.’ When she confronted her husband, ‘he went white’ she says. ‘There was this unbearable silence. Then he told me about a brief fling he’d had with a Cape Town colleague on a trip. He’d used condoms, but remembered one breaking…’
Cheryl is still with her ‘devastated but bloody contrite man – I love him’, and both have been on antiretrovirals (ARVs) for 18 months. But she sometimes uses her story at the community clinic where she works to warn patients in long-term relationships against complacency about HIV in the shadow of the Covid-19 pandemic, especially if they have men they suspect might stray. And that’s when she tells them about PrEP.
For all the success of South Africa’s national Aids treatment programmes, Statistics SA reports that HIV prevalence for those aged 15 to 40 is one in five. And according to HIV and Aids organisation Avert, the rate among young women is almost four times higher than for men the same age. In the 2020 UNAIDS report, executive director Winnie Byanyima says: ‘Genderbased violence and inequalities continue to drive the [HIV] epidemic. In subSaharan Africa, young women and adolescent girls accounted for one in four new infections in 2019, despite making up about 10% of the total population.’ And in the foreword, UN SecretaryGeneral António Guterres writes: ‘Covid-19 is colliding with the ongoing HIV epidemic, which remains enormous, unfinished business… This crisis is a wake-up call to do things differently.’
PrEP is one way women can do things differently – protecting themselves against HIV infection when they can’t always protect themselves from the behaviour that exposes them to it.
PrESENTING PrEP
PrEP is a combination of two ARVs in one pill that greatly reduces your chance of getting HIV/Aids when you take it daily. The ARVs stop the virus replicating in your T-cells (white blood
‘When I ask him to use condoms he gets angry; he says maybe I should leave.But I can’t afford to leave.’
cells that play a major part in your immunity). This prevents you getting HIV/Aids in much the same way that anti-malarial pills prevent you from getting malaria, says Dr Kevin Rebe, a Cape Town-based doctor with a special interest in infectious diseases.
Pilot PrEP projects have been run for some years in African countries, targeting the groups at greatest risk of HIV infection – men having sex with men, sex workers and serodiscordant couples (where only one partner is HIV positive). In December 2015, South Africa became the first African country to issue full regulatory approval of PrEP, including it in its national HIV programme for sex workers, then for men having sex with men. In October 2017, the Department of Health extended access to students at tertiary institutions. Now it’s scaling up the programme, focusing on other adolescent girls and young women at significant risk, says Dr Rebe, adding, however, that ‘many people are afraid to attend health services due to fear of Covid, and so might not be prioritising “non-acute” or “non-urgent” healthcare right now.’
DR Ramneek Ahluwalia, chief executive of Higher Health SA, a higher education and training health, wellness and development centre, notes that women aged 15 to 25 are most at risk of HIV infection, with about 1 200 infected each week. This has been linked to a high rate of transactional sex and low use of condoms, with studies indicating that 14% of these women have sex for money or goods.
Given the financial hardships that the Covid pandemic and lockdown have brought about, those numbers are expected to rise among middleaged women too, who, for all the advances made in achieving more equal education, employment and pay, remain largely financially dependent on men. This leads to situations where they enter into or stick it out in relationships with men they know are not monogamous, but who resist using condoms. PrEP could be an invaluable part of the solution, while pushing for gender equality.
WHAT’S PrEVENTING UPTAKE?
As of July, an estimated 69 000 to 70 000 South Africans had started using PrEP, reports PrEP Watch, an initiative of the AIDS Vaccine Advocacy Coalition. Yet the broader public has been slow to take advantage of it. Part of the problem might be that most heterosexual women are still simply not aware of it and its availability. A Wits University survey found that while most female sex workers knew of PrEP (about 4.5% did not), as did most men having sex with men (3.7% did not), almost half the general public (46%) had never heard of it.
Another part of the problem could be the way it was introduced. ‘With hindsight, the way we rolled out PrEP might have inadvertently stigmatised it,’ says Yogan Pillay, recently retired deputy directorgeneral of Communicable and Non-Communicable Diseases at the Department of Health. ‘The fact that it was offered to stigmatised groups could have discouraged young women, especially, from asking for it for fear of being labelled “high risk” or “promiscuous”.’ ‘Some also fear sideeffects and being assumed to be HIV positive because of being on the same drugs used to treat positive people,’ says Dr Rebe.
Slow PrEP uptake could also be partly down to myths around it, suggesting it causes impotence or sterility, or is being used as a way to control the population. Subjects have dropped out of trials in some African countries because of these beliefs, despite several clinical studies having disproved them.
‘PrEP is very safe,’ says Francois Venter, divisional director of Ezintsha, a newly formed subdivision of the Wits Reproductive Health and HIV Institute. ‘HIV-negative people have been exposed to it for more than five years, with no clinical consequences in the vast majority.’ It might cause ‘very slight loss of appetite and, in a small number of cases, mild nausea, which usually resolves’.
Some people have expressed fears
that taking PrEP could raise their risk of developing ARV resistance, so if they need to go on it at some stage, it might not be as effective. But Dr Rebe points out that people living with HIV take a combination of three antiretrovirals, while PrEP contains only two. ‘ARV resistance is a risk only when it’s mistakenly used by people who are already HIV positive,’ he says. ‘Resistance occurs when HIV and inadequate levels of ART [antiretroviral therapy] occur in the body at the same time. In the case of PrEP, people are negative, so there is no virus there to become resistant to the meds.’
To promote greater use of PrEP this year, the Department of Health has been encouraging primary healthcare facilities to create ‘Youth Zones’, with special times when young people can access PrEP and other HIV services, are made to feel welcome, and can get information and education material. But in March, the Covid-19 lockdown was imposed, preventing clinic attendance and stretching the health system – health focus and resources have shifted to cope with that.
AS lockdown has eased, allowing for easier socialising, and the economic crunch has set in, the number of women engaging in transactional sex is expected to rise, along with the number of women remaining in relationships where they suspect infidelity but are unable to negotiate condom use. ‘Existing data suggests that Covid-19 will deepen existing gender inequalities,’ UNICEF reported in May.
Lihle is one of many women experiencing a less visible part of the wave of gender abuse cresting in the pandemic – what the executive director of UN Women, Phumzile
Mlambo-Ngcuka, has dubbed a ‘shadow pandemic’ to Covid. ‘I wasn’t raped, beaten or killed, but I feel like a victim,’ says Lihle, a 32-year-old chef who was retrenched as lockdown hit. She knows that her partner sleeps around, but he denies it. ‘When
I ask him to use condoms he gets angry; he says I don’t trust him, that I must be sleeping around and maybe I should leave. I can’t afford to leave: he has a government job and supports me, our baby and my two kids [from a previous relationship].’
For Lihle, PrEP, which she started in July, is a lifeline. ‘If the home baking business I’ve started takes off, perhaps I can leave and stop taking PrEP. But for now, I feel safe.’
GETTING PrEPPED
PrEP is available to anyone who feels they are at high risk, and requires a prescription from a healthcare professional. It costs about R700 for Truvada or R200 for a generic drug. Since March, the Department of Health has been rolling it out in community health centres and primary healthcare clinics countrywide. ‘It’s being expanded,’ says Dr Rebe. ‘The new Department of Health Consolidated Guidelines indicate that all ART clinics will provide PrEP moving forward.’
PrEP is suitable only if you’re HIV negative. You take a pill a day, always at the same time (Lihle keeps hers with her toothpaste and takes it when brushing each morning). For women, guidelines suggest you need to take it for three weeks before you’ll be fully protected from HIV infection. And if you plan to come off it, you must continue it for 28 days after your last potential exposure to HIV. It protects only against HIV, not pregnancy or other STIs, but can be taken with any type of contraception and sex hormones. It’s considered safe for pregnant women, for those who are breastfeeding and for women who are trying to conceive. Taken as prescribed, it’s up to 99% effective in preventing transmission of HIV, explains Dr Rebe.
‘The best thing is that you can start and stop using PrEP as your risk changes, and you change your relationship or lifestyle,’ says Cheryl. ‘If you miss a pill, you’ll usually still have protection from the levels circulating in your blood.’
Long-acting injectable PrEP, vaginal rings and implants are in development, reports Venter. ‘PrEP has become an acknowledged gamechanger in terms of curbing the HIV epidemic, providing reliable and safe prevention of the virus,’ he says.
*Not her real name