On Thursday, October 26, colleagues from the Treatment Action Group (TAG), along with advocates, researchers and GPP practitioners, discussed the recommendations from the TAG’s recently released white paper, HIV Research in the Era of PrEP: The Implications of TDF/FTC for Biomedical Prevention Trials.

The effectiveness and increasing availability of oral PrEP raises questions about how it should be incorporated into clinical trial designs for next-generation HIV prevention options. This paper explores ethics, the scientific literature to date, and advocates’ views on the issue.

Recording: YouTube / Audio / Slides

Clinical trials for new HIV prevention methods offer participants counseling and access to the existing ways to protect oneself from HIV. It’s called the “standard of prevention” and is a package of prevention methods and services.

Now that oral PrEP is a proven HIV prevention method and WHO-recommended, some trials are adding it to the package. And that makes trials more complex. That’s a good problem to have, says Slim Abdool Karim, the director of the Centre for the AIDS Program of Research in South Africa, also known as CAPRISA. As the co-principal investigator of the landmark CAPRISA 004 tenofovir gel study and the recipient of multiple awards for his research, Karim brings incomparable perspective to this question. In this interview with AVAC’s Jeanne Baron, Karim talks about why designing trials with oral PrEP is a must—scientifically and ethically.

Listen here.

This interview is part of an ongoing series, and look out for our upcoming podcast—Px Pulse, which will feature interviews and discussions that explore vital topics in HIV Prevention research today. Tell us what you think!

Click on the links below to learn more about PrEP and standard of prevention in trials:

• WHO’s Ethical considerations in biomedical HIV prevention trials
• Px Wire, Vol. 10, No. 3
• PrEP Watch website

On July 4, Kenyan civil society, including groups working on the frontlines of HIV prevention and treatment, called a meeting with the leaders and implementers of oral pre-exposure prophylaxis (PrEP) activities in the country. The meeting’s purpose was to have a frank discussion about the role of community support in the national PrEP program, and touch on progress with HIV self-testing implementation. Some of the civil society groups, like ISHTAR-MSM and Bar Hostess Empowerment Support Programme (BHESP), are also involved in implementation—they’ve partnered with Jilinde, a national-scale PrEP rollout project, or LVCT to help identify potential PrEP users, spread messages and deliver services.

Other CSOs in the room, such as Survivors, an NGO of female sex workers in Busia, Western Kenya, and the Kenya Legal & Ethical Issues Network on HIV and AIDS, aren’t delivering services, but, like BHESP and ISHTAR, represent advocates, activists and potential PrEP users. All were united by a common goal of shining a spotlight on community and civil society engagement as a critical link to successful PrEP rollout in the country.

In the months leading up to the May 4 launch of Kenya’s national program, many civil society groups gave inputs to the national PrEP technical working group (TWG), convened by the National AIDS & STI Control Program (NASCOP). This work is ongoing, with civil society represented on the various rollout committees.

But being invited to the table is not the same as setting the table—and at the July 4 meeting, the organizers structured a packed agenda in order to learn about progress and plans, as well as to express their views on priority issues.

Rosemary Mburu, Executive Director of WACI Health, and Nelson Otuoma, Executive Director of the National Empowerment Network of People living with HIV/AIDS in Kenya (NEPHAK), co-facilitated the meeting.

Mburu noted that many issues remain to be worked out if PrEP is to achieve its true potential in the country: communities need to be continuously informed and engaged; sustainable financing that includes domestic resources has to be secured; and county-level plans have to be designed, with appropriate material for use at the community level.

Otuoma, who recently won the inaugural Maisha Conference Award for his work in community advocacy, reminded everyone of PrEP’s massive potential in Kenya, but only “if we can overcome barriers like stigma.”

“Just like ARVs changed the face of HIV from a killer disease to a chronic condition, PrEP can help the country move further and faster along the HIV prevention roadmap,” he said.

Jointly presenting the viewpoint of young women to the convening, 24-year-olds Anastacia Kendi and Grace Kamau, part of the youth-serving group Sauti Skika, welcomed the launch of PrEP, calling it “an empowering tool to women and girls.”

“I hope there will be more investments in ensuring the interventions are made to work for women and girls’ needs alongside the needs of boys and men.”

Three established PrEP implementation projects in Kenya—the Partners Scale Up Project; Introducing PrEP in Combination Prevention (IPCP); and Bridge to Scale (also known as Jilinde, Kiswahili for “protect yourself”)—shared updates and lessons learned.

Speakers from these projects reported excitement about PrEP as a new prevention method in the country. Yet they said that there were obstacles when it comes to actual use. While there are reports of high demand in some communities and programs, there are also places where the number of people signing up to use PrEP is lower than the expected enrollment.

Adherence (taking the pill daily as prescribed) stands out as challenge; and many people who are using PrEP have been “lost to follow-up”, public-health lingo for a participant who starts taking a medication such as PrEP or antiretroviral treatment (for people living with HIV) but along the way stops returning for their monthly refill visits without informing their clinic.

In all updates, community engagement stood out as a critical part of the solution.

Dr Elizabeth Irungu, the director of the Partners Scale Up Project in Thika and Kisumu in central and western Kenya respectively, said the project team is finding broad acceptance for PrEP among heterosexual, HIV-serodiscordant couples.

“We now have something to give the HIV-negative person,” she stated.

Partners dispenses PrEP from Comprehensive Care Centres (CCCs), clinics that are primarily involved with HIV prevention and treatment.

“We think that by adding PrEP for HIV prevention for HIV-negative people, there may be a reduction of the stigma associated with going to CCCs, as both positive and negative people can get services there. However, there is a lot of work to be done to reduce stigma around HIV, and around going to a CCC,” said Irungu.

By June 2017 the project, funded by the Bill & Melinda Gates Foundation, had enrolled 290 couples. They hope to reach 4,800 couples by 2019—200 in each of 24 centers.

Jhpiego’s Jilinde project, also funded by the Gates Foundation, is working among men who have sex with men, sex workers and adolescent girls and young women at high risk for HIV.

Tom Marwa, Senior Technical Advisor at Jhpiego, informed the convening that 2,300 users were enrolled between February and June 2017 through 17 Jilinde PrEP delivery centres in 10 counties of Kenya. The program is on track to reach 20,000 PrEP users by 2020, and its experiences will contribute important lessons to other African countries planning to introduce PrEP, he added.

Introducing PrEP in Combination Prevention (IPCP) consortium, led by LVCT Health, is implementing PrEP among the same populations as Jilinde. The project started before the national launch of PrEP and was designed to test whether PrEP could be delivered to these populations from standard healthcare facilities.

Dr Michael Kiragu, who leads IPCP, said he was heartened to see good support of PrEP during the formative studies phase of the project. Yet out of a target of 2100, only 1626 PrEP users (77 percent of target) were enrolled and retained into the program. He said that this was a sign that there were barriers to PrEP uptake and use.

The project team has learned that an individual’s community has a huge influence on their decision-making, and stigma remains a barrier to PrEP uptake and adherence, he noted.

“PrEP users at IPCP clinics complain about the rattling of pills in the bottle, the color of the pill (blue), and about disapproval from their husbands, boyfriends or parents.” To address some of these challenges clinics have started giving out cotton balls to mute the rattling of pills, holding community dialogues on PrEP with men, and offering couples counseling. In addition, people using PrEP have pointed to support groups as one of the most important resources they depend on to help them maintain good adherence.

Dr Sarah Masyuko, NASCOP’s HIV testing and PrEP Manager, gave a keynote at the convening.

The first phase of communications and advocacy on PrEP had been hugely successful, she noted, with widespread media and social media engagement reaching all corners of the country. On the sustainability question raised by civil society, Dr Masyuko said the Ministry of Health is holding consultations with PEPFAR, The Global Fund, and private companies in Kenya to secure long-term financing for PrEP.

“PrEP rollout is unlike any other,” she noted, citing difficulties with gathering reliable data for an intervention that people can get on and off at will. She said the government is looking into an electronic system with unique identifiers that will help better track users nationwide. She challenged implementing partners to do even more to reach communities with accurate messages on PrEP and HIV self-testing, and that dispel rumours and misconceptions that stand in the way of uptake among eligble persons, defined in the Kenya national guidelines as anyone at substantial ongoing risk of HIV infection.

This background information provided the platform for a robust discussion of what’s working—and what else is needed. Civil society representatives were clear that PrEP messages needed to be highly tailored and that organizations with different positions in the communities needed to have the right infomation to deliver through trusted channels. This could mean fine-tuned messages that go beyond the category of “adolescent girl or young woman,” “sex worker,” or “MSM” to consider other life circumstances—how openly a person is living with his or her identity, their community support, their influencers, et cetera. Some of this work is underway; much more will come from civil society groups leading work on the ground and feeding back on what works and what doesn’t.

From the convening, Peter Mogere, lead pharmacist at the Partners Scale Up Project and 2017 AVAC Fellow, presented a 9-point list of ‘Civil Society Asks’ to the National Technical Working Group (TWG) on PrEP, on 7 July. Along with allocating domestic resources for PrEP, the asks focus on community engagement at the grassroots level; health care provider training; and combating human rights violations, stigma and discrimination.

Mogere said the TWG was highly receptive to the civil society asks; “The TWG Chair said she was looking forward to involving the civil society in reaching out to all communities that would benefit from PrEP. She noted that civil society works on the ground in all regions of the country, including rural areas, and reaching all people at risk of HIV infection is high on the priorities of the national PrEP program.”

As a next step, the advocates are planning to stay connected and to develop and advance priorities that they can pursue through meetings where civil society sets the agenda. The history of the epidemic tells us this is how things change.

AVAC provided technical and financial support for the convening, which was co-hosted by AVAC partners WACI Health and the National Empowerment Network of People living with HIV/AIDS in Kenya (NEPHAK), in collaboration civil society organizations ISHTAR-MSM; Survivors; International Network of religious leaders living with or personally affected by HIV (INERELA+)-Kenya; National Organization of Peer Educators (NOPE); I Choose Life; Health Gap; Bar Hostess and Empowerment Programme (BHESP); Keeping Alive Societies Hope (KASH); Persons Marginalized and Aggrieved (PEMA); Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN); and Sauti Skika, a project affiliated with NEPHAK.