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Lowering the Curve of New HIV Infections

…………….Access to prep for people at high risk of infection

This week saw the SADC region hold a virtual senior officials meeting under the Theme: Rolling out Global AIDS Strategy 2021-2026, and the UN Political Declaration’s 2025 Commitments in SADC Region. However, one of the main objectives was for member states to update each other on the state of HIV in the context of the COVID-19 pandemic in the SADC region. However, we will unpack in next week’s column what the Global AIDS Strategy 2021–2026 entails and its expectations.

We have been focussing on three highly effective strategies to help prevent the sexual transmission of HIV, which when used consistently and correctly, lower the risk for sexual HIV transmission.  These include consistent and correct condom use, consistent and correct use of antiretroviral treatment (ART) by people living with HIV to maintain an undetectable viral load, as well as consistent and correct use of oral pre-exposure prophylaxis (PrEP). It is prudent to highlight that these strategies are not conclusive but are key to HIV prevention.

Last week’s focus was on  consistent and correct use of antiretroviral treatment (ART) by people living with HIV to maintain an undetectable viral load as an HIV prevention measure. This week we tackle the last HIV prevention strategy which is correct and consistent use of oral pre-exposure prophylaxis (PreP). Pre-exposure prophylaxis, or PrEP, is a highly effective HIV prevention strategy that HIV-negative people can use to lower their chance of getting HIV. Use of PrEP involves taking antiretroviral (anti-HIV) drugs and having regular medical appointments for monitoring and support. When PrEP is taken as prescribed, the risk of HIV transmission is extremely low.

What is PrEP?

PrEP is an HIV prevention method that uses antiretroviral (anti-HIV) drugs to help prevent HIV when taken by HIV-negative people. PrEP is available as a prescription pill containing two antiretroviral drugs. These same pills are also used together with other medications in people living with HIV for HIV treatment. An HIV-negative person can lower their chance of getting HIV by taking PrEP regularly, as prescribed. Most people take PrEP every day such as key populations can also choose to take PrEP on-demand. On-demand (or intermittent) PrEP means taking pills only on days before and after having sex.  In general, PrEP involves taking antiretroviral drugs on an ongoing basis, both before and after potential exposure to HIV. PrEP is not the same as post-exposure prophylaxis (PEP), which involves taking antiretroviral drugs to help prevent getting HIV after a potential exposure has happened.

Who should take PrEP?

PrEP can be used by people who are HIV negative and at high risk for HIV infection such as

  • men or transgender women who report condomless sex with men and have any of the following:
    • infectious syphilis or rectal bacterial STI in the last year
    • use of post-exposure prophylaxis (PEP) more than once
    • a high score on a valid HIV risk assessment tool
  • any person who has condomless anal or vaginal sex with a partner with HIV who is not on treatment and virally suppressed
  • people who share injection drug use equipment

The above list includes people who are likely to be at the highest risk of getting HIV. These criteria can be used to identify PrEP candidates but should not be used to deny someone access to PrEP. Other individuals may be at risk for HIV through sex or drug use and could benefit from the use of PrEP.

How can people at high risk of getting HIV access PrEP?

An HIV-negative person who wants to take PrEP needs to get a prescription from a provider who is willing to provide the necessary medical follow-up. PrEP does not need to be prescribed by an HIV specialist, but not all providers are knowledgeable about PrEP. Unfortunately, it may be difficult for clients to find a provider who is willing to prescribe PrEP.

How can service providers improve the uptake and correct use of PrEP?

Education and counselling activities related to HIV prevention should include information on the HIV prevention benefits of PrEP, along with information on other highly effective ways to help prevent HIV. These include the use of HIV treatment to maintain an undetectable viral load, post-exposure prophylaxis (PEP), condoms for sex and new equipment for using drugs. Encourage clients to choose the combination of strategies that will work most effectively for them as there are multiple ways to prevent HIV that can be combined in different ways. PrEP only helps to prevent HIV; it does not prevent other STIs (such as chlamydia, gonorrhoea or syphilis) or blood-borne infections such as hepatitis C. Discuss how PrEP fits into a comprehensive plan for health, such as regular STI testing, using condoms and using new drug use equipment.

PrEP is not for everyone. You can support clients to decide whether PrEP is right for them. During discussions, help your clients consider their level of HIV risk and the possible side effects, as well as their ability to cover the cost (i.e., insurance coverage), access a knowledgeable healthcare provider, adhere to a pill-taking regimen and attend regular medical visits. Each person has the right to decide whether or not to use PrEP as a prevention approach, on the basis of their own assessment of what is best for their health and well-being. For people who are interested in taking PrEP, provide education on how to use it correctly, to maximize safety and effectiveness. Emphasize the following:

  • PrEP should only be used by people who are HIV negative.
  • PrEP should only be accessed through a healthcare provider.
  • PrEP requires that people be highly adherent to PrEP medications.

People who want to start taking PrEP should first be tested for kidney function and screened for STIs and hepatitis A, B and C. People who are taking PrEP should have regular clinic visits with a healthcare provider, typically every three months. During these visits they should be tested for HIV and STIs, monitored for side effects and toxicity, and given adherence and risk-reduction counselling. Whenever possible, be aware of — and develop partnerships with — local healthcare providers, clinics and health centres that are willing to prescribe PrEP. By establishing these connections, you can ensure that you will be able to link clients who want to use PrEP to a location where it is available.

Encourage and support clients to communicate openly with their sex partners. Consider couples-based counselling for people in relationships (whether monogamous or not). This may help to create a supportive space for couples to come to a consensual agreement on how to lower their chances of HIV transmission, find ways to support each other in using HIV prevention strategies consistently and correctly, and discuss potentially sensitive issues relevant to HIV prevention.