RHI
AVIWE

PrEp

HIV prevention
When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling
Posted: Jan 27, 2017
Category: PrEp

When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling

Oral pre-exposure prophylaxis (PrEP) using the antiretroviral drug emtricitabine/tenofovir disoproxil fumarate (Truvada) has been shown to dramatically reduce the risk of HIV acquisition for women at higher risk of infection if taken daily. Understanding when and why women would intentionally stop using an efficacious oral PrEP drug within the context of their ‘normal’ daily lives is essential for delivering effective PrEP risk-reduction counselling. As part of a larger study, we conducted 60 qualitative interviews with women at higher risk of HIV in Bondo, Kenya, and Pretoria, South Africa. Participants charted their sexual contacts over the previous six months, indicated whether they would have taken PrEP if available and discussed whether and why they would have suspended PrEP use. Nearly all participants said they would have used PrEP in the previous six months; half indicated they would have suspended PrEP use at some point. Participants’ reasons for an extended break from PrEP were related to partnership dynamics (e.g., perceived low risk of a stable partner) and phases of life (e.g., trying to conceive). Life events (e.g., holidays and travel) could prompt shorter breaks in PrEP use. These circumstances may or may not correspond to actual contexts of lower risk, highlighting the importance of tailored PrEP risk-reduction counselling.

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Pre-exposure prophylaxis in Southern Africa: feasible or not?
Posted: Jan 27, 2017
Category: PrEp

Pre-exposure prophylaxis in Southern Africa: feasible or not?

Introduction: Southern and Eastern Africa bear the brunt of the AIDS epidemic, and current prevention interventions remain inadequate. Antiretroviral-based pre-exposure prophylaxis (PrEP) is gaining momentum as an effective prevention intervention. Discussion: Discussions have been started on how this strategy could be employed in Africa such that the populations most in need can be reached urgently for the greatest impact.This requires the selection of specific risk groups and service environments in which PrEP can be distributed safely and cost effectively while being mindful of any ethical issues.
Conclusions: Given the need for an integrated public health approach to this, a number of potential populations and opportunities for PrEP distribution exist and are discussed in this commentary.

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Tenofovir Pre-exposure Prophylaxis for Pregnant and Breastfeeding Women at Risk of HIV Infection: The Time is Now
Posted: Jan 17, 2017
Category: PrEp

Tenofovir Pre-exposure Prophylaxis for Pregnant and Breastfeeding Women at Risk of HIV Infection: The Time is Now

Pre-exposure prophylaxis (PrEP) using either daily oral tenofovir disoproxil fumarate (TDF) or co-formulated TDF/emtricitabine (TDF/FTC) has been shown in clinical trials to be effective for prevention of HIV acquisition in men who have sex with men, heterosexual men and women, and persons who inject drugs . However, unfortunately, the relevant clinical trials excluded pregnant or breastfeeding women; the trials included frequent pregnancy testing, and PrEP was discontinued if pregnancy was recognized (generally at gestation months 1–2).

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Rethinking HIV prevention to prepare for oral PrEP implementation for young African women
Posted: Jan 17, 2017
Category: PrEp

Rethinking HIV prevention to prepare for oral PrEP implementation for young African women

Introduction: HIV incidence remains high among young women in sub-Saharan Africa in spite of scale-up of HIV testing, behavioural interventions, antiretroviral treatment and medical male circumcision. There is a critical need to critique past approaches and learn about the most effective implementation of evidence-based HIV prevention strategies, particularly emerging interventions such as pre-exposure prophylaxis (PrEP).
Discussion: Women in sub-Saharan Africa are at increased risk of HIV during adolescence and into their 20s, in part due to contextual factors including gender norms and relationship dynamics, and limited access to reproductive and sexual health services. We reviewed behavioural, behavioural economic and biomedical approaches to HIV prevention for young African women, with a particular focus on the barriers, opportunities and implications for implementing PrEP in this group. Behavioural interventions have had limited impact in part due to not effectively addressing the context, broader sexual norms and expectations, and structural factors that increase risk and vulnerability. Of biomedical HIV prevention strategies that have been tested, daily oral PrEP has the greatest evidence for protection, although adherence was low in two placebo-controlled trials in young African women. Given high efficacy and effectiveness in other populations, demonstration projects of open-label PrEP in young African women are needed to determine the most effective delivery models and whether women at substantial risk are motivated and able to use oral PrEP with sufficient adherence to achieve HIV prevention benefits.
Conclusions: Social marketing, adherence support and behavioural economic interventions should be evaluated as part of PrEP demonstration projects among young African women in terms of their effectiveness in increasing demand and optimizing uptake and effective use of PrEP. Lessons learned through evaluations of implementation strategies for delivering oral PrEP, a first-generation biomedical HIV prevention product, will inform development of new and less user-dependent PrEP formulations and delivery of an expanding choice of prevention options in HIV prevention programmes for young African women.

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PrEP implementation research in Africa: what is new?
Posted: Jan 17, 2017
Category: PrEp

PrEP implementation research in Africa: what is new?

Introduction: Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO’s criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings. Discussion: In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.
Conclusions: Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.

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