Lessons on rolling out an HIV prevention pill in South Africa

Last year South Africa became the first country on the continent to register the use of a drug that could be used as an oral pre-exposure prophylaxis for HIV prevention. Pre-exposure prophylaxis, referred to as PrEP, is the use of anti-retroviral drugs by people who do not have HIV to prevent them from becoming infected.

The idea behind PrEP has been to target high risk populations where new infections remain consistently high. This includes sex workers, men who have sex with men, injection drug users and young women.

Following a recommendation by the World Health Organisation to use the drug as an additional HIV prevention choice South Africa registered Tenofovir/Emtricitabine last year.

By June this year South Africa’s PrEP programme was being implemented at 17 sites that were serving sex workers and men who have sex with men. The programme had also been expanded to provide the drug at nine clinics at seven tertiary institutions which serve more than 120,000 young people.

The PrEP rollout data shows that there is a relatively slow, but increasing, uptake of PrEP. There are concerns. One year after the licence was procured there are fears that the rollout isn’t sufficiently targeting one of the country’s most high risk populations: young women.

This is a critical cohort of people in the fight against new HIV infections. Studies show that young women in South Africa, aged between 15 and 24 years have the highest HIV incidence. About 1,745 new HIV infections occur among these young women every week.

An additional factor that makes the group so important in bringing down infections is that they represent a substantial section – about 10% – of the population.

Unless this problem is solved the rates of new infections in South Africa are unlikely to be reduced.

Great idea, challenging to deliver

After South Africa procured the licence for the HIV prevention tablet, the National Department of Health launched a national policy and set of guidelines to rollout PrEP and provide test and treat services. Test and treat allows people to access antiretrovirals as soon as they test positive.

The government’s cost-effectiveness analyses suggested that the greatest impact of PrEP would be in populations that have a substantial risk for HIV infection. As a result the policy focused initially on providing PrEP at a limited number of sex worker sites. This would help them learn more about real world delivery prior to scale up.

But here lies the issue. There is a high level of political will and desire in the government to rollout PrEP to young women who are at risk, but the health system requirements are complex. Cost is also a consideration. There is a need to establish how best to identify young women at highest risk and how best to offer and retain young women on PrEP.

Next steps

PrEP is new technology that has the potential to alter the HIV epidemic particularly among women. But a narrow focus on a single technology alone is unlikely to solve health and social challenges associated with HIV.

South Africa needs to pay careful attention to access and service delivery issues and constraints, and to engage communities as PrEP is scaled up so that its potential is fully realised.

There are a number of small scale research projects mainly in and around Johannesburg and Cape Town that could help inform how best to deliver PrEP to young women. More than 500 adolescent girls and young women between the ages of 16-24 years are being enrolled in the projects. The aim is to to learn more about scalable models of PrEP delivery for adolescents in countries like South Africa which has limited resources.

Without an understanding of best practices and most cost effective scalable delivery models for young women, it will be challenging for South Africa to maximise the impact of core HIV prevention, treatment, and care interventions.

Another critical step to filling the gaps would be to generate greater community awareness about PrEP. Many people don’t know that there is an antiretroviral pill that, if taken every day, can reduce a person’s risk of being infected with HIV. Getting the message across is difficult because the legacy of concerns about antiretrovirals and their side effects persist in many communities.

This is not just about awareness but about the need for a broader conversation about how we address the underlying issues that continue to shape HIV risks in young women. Stigma, violence against women, judgemental attitudes about young people having sex all make it more difficult for people to accept PrEP and to use it effectively.

A broader conversation is needed to increase knowledge and awareness of PrEP, its potential to change the course of the epidemic, and where it fits in to a broader programme of HIV prevention.