Nation awaits PrEP roll-out
Late last year, Zimbabwe adopted the new World Health Organisation (WHO) guidelines that will see the roll-out of ARVs to highly exposed HIVnegative people to curb new infections as part of efforts towards zero new infections by 2020.
VICE President Emmerson Mnangagwa announced this while officiating at the 2016 World Aids Day commemorations in Kwekwe. The day, set aside by the global health body, is commemorated during the first week of December every year.
“Pre-exposure prophylaxis (PrEP) for those people who are at high risk of contracting HIV has also been introduced with these guidelines,” he said back then.
PrEP is the use of anti-retroviral drugs (ARVs) to protect HIV-negative people from HIV before potential exposure that can lead to HIV infection. Truvida is currently approved in Zimbabwe for use as PrEP. It is a single pill that is a combination of two ARVs — Tenofovir and Emitricitabine.
Put simply, PrEP is akin to taking anti-malarial tablets before visiting a malaria-infested zone.
Chief among the potentially exposed are sero-discordant couples (where in a relationship one is HIV-positive and the other negative), commercial sex workers, nurses, clinicians, young women and caregivers for infected people.
Young women have traditionally existed as a subordinate group and their ability to negotiate for safe sex is limited, hence PrEP offers them a real option to take charge of their lives through prevention of HIV infection.
Although this initiative is noble, questions abound as to whether Zimbabwe has the capacity to carry out the exercise (with a possibility of overburdening the current budget allocated to the health sector).
There is also the issue of adherence, stigma associated with taking ARVs (by the HIV-negative population) and the accessibility of such medications.
The Director of HIV/Aids and TB Services in the Ministry of Health and Child Care, Dr Owen Mugurungi, says while they have the guidelines and appreciate the stance and associated benefits prescribed by WHO for the country to join a number of other nations that have since adopted the exercise (such as Kenya and South Africa), the element of capacity cannot be ignored.
“We have the guidelines but have not started because of resource limitations,” said Dr Mugurungi.
Doctor David Okello, the WHO’s country director echoed the same sentiments.
“PrEP is a new programme and the Ministry of Health is in the process of developing the roll-out plan, quantifying how much medicines will be required and also developing the monitoring and evaluation tools to monitor implementation in the country,” said Dr Okello.
He, however, said the ministry was offering PrEP under various projects, although on a low scale.
“The Ministry of Health, in partnership with PEPFAR, began offering PrEP in six districts about a year ago under the DREAMS project. It has also been offered to sex workers under the CESHAAR project.” he said.
As with other HIV services, stigma and discrimination can negatively impact uptake and adherence to PrEP. In some settings, PrEP is associated with high risk of sexual activity further compounded by the fact that it also has the stigma of being related to HIV.
Hence there are fears that those exposed might deny taking the medication.
In addition, the country has been experiencing a shortage of basic medication and pharmaceuticals. With PrEP coming up, accessibility of the medication can prove to be a tall order and there is a possibility of overburdening the already meagre health budget. Then there is the issue of adherence. “The medication is supposed to be taken seven days before potential exposure and for those in the commercial sex business, they should be prepared to be on the drugs for life,” said Dr Justin Dambaza, an HIV expert.
Commercial sex workers — who constitute a great percentage of the targeted beneficiaries — are of the view that taking the drugs for seven days can be a daunting task.
“It is very difficult to take them that way because I am exposed everyday and I can’t stomach the possibility of taking the drugs daily. People will end up thinking I am on ART,” said one commercial sex worker.
Most people are also wondering how people on PrEP and ART will be differentiated.
“There are going to be problems in separating a person on ART and someone on PrEP,” said Fungisai Sinaro, an HIV activist.
He was also worried about the spread of sexually transmitted infections (STIs).
“If people start depending on PrEP, there will be STIs. People should know that the drugs won’t stop the spread of STIs,” he said.
In 2015, WHO released new guidelines and a policy brief recommending that PrEP should be offered as a choice to people who are at a substantial risk of contracting HIV.
If not taken routinely, PrEP is much less effective and it is therefore important that any programme offering PrEP provides the service as part of a combination package of prevention initiatives. It does not have to replace other effective methods like condoms.
PrEP reduces the risk of HIV transmission by 90 percent.
Zimbabwe is targeting zero new infections by 2020 and PrEP, combined with other measures like male circumcision and use of condoms, are expected to play a key role in the attainment of the target.
There is need for urgent collaborative engagement between the Ministry of Health and Child Care, National Aids Council and various health stakeholders for proper health education on the matter.
While it may help in reducing the rates of HIV infection, PrEP cannot prevent the spread of STIs. There is need for adequate resources to ensure availability and accessibility of the drugs.
Currently, the country is operating on resources generated locally through the Aids levy and external funding.