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One of the biggest developments in HIV in the last decade or so was the discovery that certain antiretrovirals are highly effective at preventing HIV infection. Yet, the provision and uptake of such HIV pre-exposure prophylaxis (PrEP) have been slow, particularly in South Africa, where HIV infection rates in young women and girls remain stubbornly high.
But there are signs that the tide may be turning, both here and internationally.
“It’s really encouraging to see quite rapid increase in PrEP initiations over the past five years,” Dr Rachel Baggaley, of the World Health Organization (WHO), told attendees at the recent Conference on Retroviruses and Opportunistic Infections (CROI).
Despite the increases, Baggaley said that it is not enough and the roughly 1.5 million PrEP initiations by last year are still way below the WHO’s targets (three million by 2020). She said that outside of Eastern and Southern Africa around 75% of people starting PrEP are men, while in East and Southern Africa around 70% are women.
The three Cs
Speaking to Spotlight, Professor Linda-Gail Bekker, Director of the Desmond Tutu Health Foundation says the uptake of oral PrEP in South Africa “has frankly gone disappointingly slowly”. Yet, she points out that when they run trials, there is good interest. “We think it might be about having to go to clinics to get the PrEP and also a lack of positive demand creation,” she says.
Bekker says young healthy people don’t really want to queue at clinics and that, as with vaccination, the 3Cs are crucial.
“You need to address convenience. You also need to address complacency [since] people don’t think they are at risk and don’t necessarily see the need or the urgency. Finally, we need to address confidence. They need to feel good about taking it.
"It is safe and effective and really can be good for their lives and wellbeing,” she says. A paper by Bekker and co-authors published in the journal PloS One suggested that PrEP uptake was facilitated when offered as part of an integrated sexual reproductive health service but hampered by low awareness, stigma, and misconceptions about it in the community.
According to Bekker, there has been some uptake in KwaZulu-Natal, Eastern Cape, Gauteng, and Western Cape. She thinks this might be attributed to these areas having the most HIV programmes and related resources.
Government has progressively made oral PrEP available at more public healthcare facilities over the last two to three years. As we previously reported, by end June 2021, PrEP was provided at 1 851 public healthcare facilities in South Africa – which is just over half.
Offering PrEP at schools
If one problem is that healthy young people tend not to want to go to clinics, an alternative might be to offer them PrEP at schools. Senior Researcher at the Wits Reproductive Health and HIV Institute (RHI) Nicolette Naidoo presented such a school-based model at CROI.
The school-based model involved providing PrEP and other services from a mobile clinic parked at a high school either inside or outside of school premises, depending on the school’s policy. The mobile van is usually in the area every day of the week, although it moves around and may be at a specific school only one day a week.
The programme, funded by USAID, runs from 2018 to 2023 and operates in seven provinces and 14 districts. North West and Northern Cape were not included. They aim to reach female clients aged 15 to 29 and males aged 15 to 34 and to add 35 750 new PrEP clients.
The programme is not just about PrEP, however. Multi-disciplinary teams made up of clinical mentors, nurses, HIV counsellors and demand creation officers, among others, aim to give a holistic service to a learner and refer them to other services if needed. With this model, they say they are able to provide HIV testing and counselling, PrEP, mental health, STI screening, and gender-based violence services.
Naidoo says the need varies according to areas, so you will have a bigger team in some areas and a smaller team in others. “For example, here in Joburg, they have a team with five nurses, which is a lot because it is big and this might not be the case in other areas. The team also depends on the targets that have to be met. Districts are different, therefore the team is built according to the need in that area,” she says.
For their last financial year running from 1 October 2020 to 30 September 2021, Naidoo says they have seen amazing success from all the seven provinces they work in. “An example of this is where we see 18% of adolescent girls and young women provided with contraceptives and PrEP. [We have] almost universal coverage with 99% of PrEP beneficiaries screened for STIs,” she says. Around 60% of beneficiaries continue on PrEP after the first month. These figures are for all the districts that they work in combined.
Driving demand
Naidoo says one of the things that they quickly realised is that they require multiple strategies to drive demand and uptake of PrEP. This included having HIV prevention ambassadors in communities and learner support agents at schools they worked with. This, she says, “allowed for an enabling environment for the delivery of PrEP at a school level”.
“We also have a very detailed social mobilisation for community entry strategy. This means talking to the influencers in the community, the leaders, educators before we even start working in that area to inform and mobilise people about what we will be doing. So we [are] really working with gatekeepers to ensure that there is an enabling environment in the community to foster normalisation of PrEP but also increase awareness and create demand for the services.”
Also important, she says, was leveraging digital innovations like social media, the myPrEP journey app, posting the mobile roster (plan detailing where and when the mobile clinic will be in the area) but also working with community radio stations.
Naidoo points out that the project was integrated with and implemented in the context of South Africa’s Integrated School Health Programme (ISHP). This helped when they had to engage with school governing structures and communities.
“Our process is generally [to] go in as multiple partners. We are sensitising the school governing body, parents, minding that those conversations can be quite lively,” she says.
Naidoo explains that they invest time in working with parents, talking through the policy and the implications of a young person being sexually active and not using a condom. “In South Africa at the moment, there is a massive problem around unplanned pregnancy or teenage pregnancy.
"So [we are] speaking to parents [through] an empathic lens [about] what this means for their child—not necessarily the other children in their community but what this means for your [their] child [and the] child’s ability to complete school. That has been our approach with parents, educators, traditional leaders, and chiefs in communities and so we continue to learn from communities.”
Better understanding of the PrEP journey
While such school-based programmes may have an important role to play for learners, experts point out that additional support will be needed to facilitate more convenient access to PrEP for people who are no longer in school.
“We need to understand young women and adolescent girls’ PrEP journey,” says Baggaley. \
“Women are going to start PrEP today, continue for the next year, next two years, next five years, or next ten years. They will start, stop, and restart and potentially in the future switch products. We really need to think about that in the way we deliver and support them in their choices.” She said the WHO will soon release new guidelines on differentiated PrEP delivery that will address some of these concerns.
Finally, to increase uptake of PrEP in young women and adolescent girls, Baggaley says there is a need for much better and more positive messaging.
*This article was published by Spotlight – health journalism in the public interest.
