Teresia is a seasoned advocate for gender equality and sexual reproductive health and rights, especially for HIV-positive women. She is passionate about promoting HIV prevention strategies that work for women and girls. Teresia was a 2014 AVAC Advocacy Fellow and a founding member of the Personal Initiative for Positive Empowerment (PIPE Kenya). She is the vice chairperson of ICW-EA and represents the region in the ICW Global International Steering committee. She is a counselor by profession and currently volunteering with ATHENA Network in community engagement on gender eqality and HIV.

In 2014, at the peak of my excitement as an HIV prevention advocate and an AVAC Fellow, the first Research for Prevention (R4P) Conference was held in Cape Town. I left that conference anxious but hopeful about a few things: The outcome of the FACTS 001 microbicides trial, the outcome of PrEP demonstration projects in different countries, how implementation in the real world would look, and the start of the much-talked-about ECHO trial that will answer key questions about whether certain hormonal contraceptives increase the risk of HIV acquisition.

In the time in between Cape Town and Chicago a lot has happened in all of these areas, and so much remains to be done.

A few months after leaving Cape Town, new findings came out about FACTS 001. There was no evidence of overall protection associated with the gel tested. Younger women were not correctly and consistently using the gel, and therefore were not protected.

Results from PrEP demonstration projects showed that discordant couples using oral PrEP had very low levels of HIV transmission – reducing the risk by up to 96 percent. More demonstration projects with different populations are currently underway and will answer questions related to implementation. In Kenya and Uganda, the open-label demo projects continue to record high adherence rates among discordant couples.

We know PrEP works but availability is limited. In most African countries, PrEP is not yet part of public health programs. In a few places it can be obtained at demonstration sites that target specific populations. Kenya and South Africa are the only African countries where Truvada (the brand name for drugs used as PrEP) has been approved and it is now available in South Africa’s public health system for certain high-risk populations. Regulatory applications have been submitted in Botswana, Lesotho, Malawi, Mozambique, Swaziland, Tanzania, Uganda and Zambia (see complete global map here).

“People at high risk of HIV are more likely to take PrEP if [they are] drawn out,” said Dr. Elizabeth Irungu of the Kenya Medical Research Institute who was in Chicago for R4P. Drawing out people at high risk means many things including outreach, reducing stigma, and using innovative approaches to overcome structural barriers such as distant or understaffed clinics, prejudiced service providers. It also calls for training health workers and strengthening health and community systems. We still don’t have PrEP guidelines in most countries; Kenya for example has made big strides in PrEP and other prevention tools, yet policy makers are yet to develop guidelines, which instruct health workers on how to administer PrEP. At R4P 2016, Kenyan policy makers promised to do so by 2017.

In the US, PrEP is widely available to those at risk. However, there are disparities in access there too: 70 percent of those accessing PrEP are men; although 75 percent of new infections are among people of color, only 25 percent of them are accessing PrEP. And the disparities go on and on. Communication campaigns should reach out to women and people of color who are at higher risk of acquiring HIV.

The discussion around hormonal contraception and the risk of HIV acquisition was filled with uncertainty in Cape Town. The World Health Organization (WHO) had issued a statement that women at high risk of HIV should be encouraged to use condoms alongside the hormonal contraceptive known as Depo-Provera. The uncertainty about Depo’s effect on HIV risk stems from conflicting and unclear observational data. Only a randomized controlled trial can resolve the question, “Do hormonal contraceptives like Depo-Provera increase the risk of HIV acquisition?” When ECHO was initiated advocates called for a four-arm trial but with not enough resources ECHO kicked off as a three-arm trial of Depo-Provera (or depo), a copper intrauterine device (IUD) and Jadelle (an implant). NET-EN, another injectable and potential fourth arm of the trial, was omitted from ECHO. What do we do in the meantime as we wait for ECHO results?

For me, the human rights issues are striking. Women considering Depo-Provera need accessible and complete information about this issue so they can make informed decisions. WHO is slow to respond to additional data about Depo’s potential for increasing risk and inconsistent in continued engagement with local communities in Africa.

Civil society organizations and advocates will continue to push for a mix of birth control methods and the funding to support it in all settings, including rural areas so that women will have a range of options to choose from. Engagement and consultations between WHO and advocates must continue. Conversations should be brought to communities; leaving no one behind. Most importantly, the conversation should be taken to the broader movement for sexual and reproductive health and rights (SRHR). All stakeholders should work and collaborate with sites that deliver reproductive health services, keeping PrEP access a high priority along with other SRHR services.

Sitting in a Chicago conference center, R4P’s home this year, I heard calls for innovation, with more and better tools that women can use and control. And leaders were calling for engagement across the biomedical frontier. “We need to work towards an HIV cure,” urged Ambassador Deborah Birx of PEPFAR, while also calling for the delivery and implementation of what we have. In short, Birx said we need to integrate programs, disseminate science, and engage communities meaningfully to shape the agenda for research and implementation.

Although there’s a lot that needs to be done to make Amb. Birx’s hope a reality, I’m more hopeful after Chicago than I was after Cape Town. Science continues to deliver – now it’s time for us as advocates, service providers, governments and funders to effectively implement what’s been delivered to us as we work towards new possibilities for tomorrow.

Maureen coordinates an advocacy project that aims at improving the participation of people living with HIV and key populations in the Global Fund and PEPFAR processes in Malawi. She is very passionate about HIV prevention efforts for young women and girls. Maureen was also a 2015 AVAC Fellow.

Let me start by posing these questions: how many young women are having sex in your community? How many of those are having it safely? And how many of those are having it consensually?

All these questions are coming alive as I type this, anticipating that the answers could be provided by the scientists who I rubbed shoulders with at the 2016 HIV Research for Prevention (HIVR4P) conference. HIVR4P is the only global conference that brings together researchers and community advocates from all over the world, in support of the cross-fertilization of work on HIV vaccines, microbicides, PrEP, treatment as prevention, and other biomedical prevention approaches. R4P provides a forum to discuss research findings alongside community experiences. This year the conference was held in Chicago, USA with almost 1,500 delegates in attendance.

About three weeks ago I came across a very disturbing story of a young girl who was raped by seven men. Chikondi (name changed to keep her identity confidential) is a 14-year-old girl who comes from a rural part of Salima District in Malawi. The son of the community’s traditional leader was celebrating his birthday. To show solidarity, community members on such occasions are expected to celebrate with the family. Such celebrations are usually conducted at night and are known as “Mchezo” in my local language.

On the night of the celebration, Chikondi and her younger sister attended the night party. Around 11pm, whilst the party was still going on, Chikondi and her sister decided to leave early. They were assured that it was safe for them to travel back home since the community was still awake. On the way home they met seven men who raped Chikondi, but she managed to identify one of the boys. The issue was reported to the traditional leader of the community who ruled that each of the seven men should pay 10 dollars. Out of that money 20 dollars was given to the parents of Chikondi as compensation and the case was closed.

When I heard the story my heart broke. I thought of Chikondi, I thought of the trauma and psychological torture she was going through. I asked myself, what if one of the men was HIV-positive? What if one of them had STIs? And then I thought: how many other young women in Chikondi’s community are being sexually abused? Maybe you have some answers. But I don’t. So many thoughts lingered my mind. And then for a minute, I asked myself, “What if post-exposure prophylaxis (PEP) was readily available and accessible in Chikondi’s community? Or what if pre-exposure prophylaxis (PrEP) was one of the HIV prevention interventions readily available to young women in Chikondi’s community? What difference would it make in Chikondi’s situation?

Unfortunately, this is far from the reality. Despite the fact young women and girls are continuously being subjected to sexual abuse that puts them at risk of HIV (not to mention host of other threats to mind and body), there are still limited options available when it comes to HIV prevention interventions. Condoms, which are not readily available, remain the only HIV prevention interventions available for young women in Malawi. Yet young women and girls don’t have the power to negotiate for safe sex.

On the other hand, our policy makers have taken a stand: In Malawi as a country, they say, we are not ready for interventions like PrEP.

After listening to numerous presentations and stories from different research experts and community advocates I have learnt that young women and girls are indeed at risk. There are over 7,500 young women getting infected with HIV every week. From the conference I have also learnt that PrEP works if taken every day. Currently, there are few countries where PrEP is now accessible to the general public. And my question is when will PrEP be available in Malawi? When will Malawi be ready for PrEP? If we are saying our girls don’t need PrEP then what are we offering them instead?

It is time to act. We cannot wait anymore. Not when our young women and girls are continuously being put at risk of HIV.

As PrEP begins to reach communities throughout the world, access to this groundbreaking HIV prevention medication cannot be taken for granted. In many cities and rural areas in Africa, PrEP is still a foreign idea instead of an exciting new approach that can save lives. This blog is the latest in our series of updates on PrEP advocacy in Africa. This month, we are in Zambia and our focus is on a coalition focused on key populations (those considered to be at high risk for HIV), and it just kicked off its advocacy work.

While the gay community in the US strongly advocates for PrEP and backs education campaigns to reach those at high risk of HIV, the gay communities in African countries, and other places with gay populations that are mostly not white, have yet to show this kind of support and enthusiasm.

This has left a majority of Africa’s gay men without knowledge of or access to PrEP. And even those who do know about it are unsure what steps to take or what message to share with their friends. But the good news is—this is changing very rapidly. The voices of gay men in Africa are raising questions now about PrEP, creating platforms for advocacy, forming strategies for creating demand and working with national governments to develop guidance for implementation. Just last month the PrEP train stopped over in Uganda and Kenya where gay men in those countries came together to create an advocacy platform focused on rolling out PrEP to at-risk populations.

In October, PrEP advocacy picked up in Zambia. Friends of Rianka, Trans Bantu and Treatment Advocacy and Literacy Campaign (TALC) worked together, with support from AVAC, to convene a multistakeholder meeting on PrEP.

The meeting, which took place on October 10 in Lusaka, included different stakeholders from communities of men who have sex with men (MSM) and lesbian, gay, bisexual, trans & intersex (LGBTI) people. The participants discussed the current national context for rolling out PrEP for MSM in Zambia. The group identified the need to develop a strategy (with division of labor, resource needs, etc.) with a focus on raising awareness, creating demand and policy advocacy, all aimed at winning increased access to PrEP among MSM in Zambia. The meeting, also attended by government and donor agencies, presented an opportunity for the community to create an advocacy strategy that goes beyond PrEP and MSM, to one that touches on other biomedical interventions for HIV prevention within key populations in Zambia—a gap everyone in the room thought needed to be filled.

The group identified some critical steps for rolling out PrEP in Zambia:

• Revise The 2017 National AIDS Strategic Framework (NASF) guidelines and align them with recommendations related to PrEP in Zambia, developed from this day’s consultative meeting.
• Prioritize existing funding for key populations to support access to PrEP for MSM and LGBTI.
• Use existing knowledge of PrEP to inform next advocacy steps. Advocate for PrEP uptake as an entry point for other services such as Voluntary Counseling and Testing (VCT).

After identifying these steps, a nine-person Zambia Key Populations Biomedical Advocacy group was formed and will carry out recommendations developed below:

• Engage governments to support the uptake of PrEP
• Collaborate with health service providers to develop a strategy for the provision of PrEP
• LGBTI community in Zambia to set PrEP literacy as a top proirity
• Consultations with key population constituencies in all of Zambia’s districts
• Demand creation
• Create PrEP champions who will act as PrEP Peer Educators

This group will be working in the coming days and weeks with the government and donor agencies to implement these recommendations. We are very excited to be supporting these initiatives, in partnership with amfAR, and led by African gay men.

We know that when people have information and knowledge about an HIV prevention tool, they take action. Early in the epidemic, the government and donors supported prevention efforts in the MSM communities around condom education. PrEP is no different. African gay men need to be provided with information that is culturally sensitive. New prevention campaigns, targeted just for them, are needed. They need the financial and moral commitment of the society around them, to support efforts to educate their communities about all available prevention options, including PrEP.

Often this work involves the patience to move one step at a time, sometimes falling back before heading forward again. In Zambia, a group of dedicated MSM activists just took several long strides forward all at once, and we look forward to being there as they round the corner, bringing PrEP with them to Zambia’s gay community.

Stay tuned.