To Be PrEP-ared for the Future, We Must Learn from the Past

December 6, 2016

Simon K’Ondiek is a 2011 AVAC Advocacy Fellow, hosted by the Nyanza Reproductive Health Society in Kisumu, Kenya. He is an HIV prevention research advocate with vast experience in the mobilization of communities to effectively engage with HIV prevention research and educating these communities on clinical trials around them.

Five years ago, I was an AVAC Advocacy Fellow. At the time, voluntary medical male circumcision (VMMC) was just beginning to be rolled out in sub-Saharan Africa. Kenya, where I live, was out in front of many other countries but even then, there were problems and challenges—getting information out about what the intervention did and didn’t do, encouraging adult men to take up the procedure, fostering support from female partners, spreading the word, persuading traditional leaders to take it up—I spent my fellowship working on these things. The year culminated in a documentary photography series, exploring themes centered on the knowledge, attitudes, communication and behavioral intentions of young men and women as VMMC rolled out in Nyanza Province. I also built an advocacy task force to work in the province and monitor the rollout.

All of that work was triggered by a joint recommendation in 2007 from the World Health Organization (WHO) and UNAIDS. It called for the adoption of VMMC as an additional strategy for HIV prevention in priority countries. A subsequent document, Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa, identified key success factors for VMMC. These include leadership and governance. Steadfast political support, if sustained through the entire process of implementation, results in much greater uptake. Engaging national champions (such as Prime Minister Raila Odinga who became one of the key faces of VMMC in the region), developing national policy and operational plans, and designating a spokesperson for the national program helped bolster VMMC uptake in Kenya. I focused on community-level work and can say from first-hand experience that rollout without comprehensive community engagement beforehand almost brought VMMC to its knees. Few men showed up at clinics to be circumcised, and local leaders balked at the idea of circumcision, considering it a foreign intrusion. Something had to change to address these and other challenges. And when communities and traditional leaders were more meaningfully engaged, the pace of rollout intensified.

So much of what I did in that fellowship is applicable today—especially when it comes to PrEP. Here is what I wish everybody knew, and would carry forward as they plan for the kind of comprehensive engagement that made VMMC a reality in Kenya.

For PrEP to be effective community-wide, it will take strong leaders, resources, and the engagement of multiple stakeholders, including health service providers, clinic by clinic. Pre-exposure prophylaxis, or PrEP, for HIV prevention involves the use of antiretroviral medications, known as ARVs, to reduce the risk of infection in HIV negative people. Oral PrEP uses a two-in-one antiretroviral (ARV) pill, containing the ARVs tenofovir and emtricitabine under the brand name Truvada. These ARVs were originally developed to treat people who have already acquired the virus. As a pill taken as HIV prevention, several trials have found PrEP to be safe and effective if taken correctly.

PrEP implementation shares similarities with other sexual and reproductive health products being implemented across sub-Saharan Africa. Contraceptives, like PrEP, are also safe and very effective if used. Adherence in both cases is essential. PrEP is highly protective for both men and women. Similarly, a condom also protects both men and women from contracting sexually transmitted diseases (STIs) and prevents unintended pregnancies. Voluntary medical male circumcision (VMMC), PrEP, condom use and other safe sex practices represent a range of options that can be used in combination and tailored to individual needs.

Numerous demonstration projects aim to establish the benefit of PrEP in the real world, outside the controlled environment of a clinical trial. As access expands, oral PrEP will surely face several challenges.

One example, a lack of awareness of available options, and lack of access to services adversely impacts the health of women, and children too. For PrEP implementation to be effective, administrators must overcome a similar lack of awareness and create access for those most vulnerable to HIV. Key populations need to know it’s available and effective. These groups, including sex workers, adolescent girls and young women, men who have sex with men (MSM) and discordant couples, must be engaged.

Consider this: in places where family planning needs are great, common explanations given for not using family planning methods include health concerns, side effects, poor access to products and services, partner reluctance and prohibitive costs. In some place, family planning challenges have been overcome by integrating HIV treatment and maternal and child health (MCH) services, training healthcare workers, engaging male partners, and continually building awareness of the availability of family planning services through TV and radio to reach a wider community.

It’s also important to note two other factors shaping local context: poor attitudes among health care workers hold back the uptake of family planning services, especially for adolescents and young women. And the involvement of men in family planning plays an important role, as women in many developing countries are not empowered to take family planning decisions on their own.

Therefore, successful PrEP implementation at the community level depends upon engaging those most vulnerable to HIV, and address these real-world challenges. They need to be aware of the availability, the side effects, the benefits. Unforeseen obstacles must be addressed as they arise to ensure successful rollout and uptake.

At the national level, we must operationalize PrEP guidelines and work with politicians to secure political will for a sustained delivery model. Well-coordinated community education and literacy programs are needed at the outset to explain PrEP and identify challenges such as stigma and the under-use of reproductive health services.

Government campaigns on TV, radio and posters, with support from local NGOs and local opinion leaders, should be considered. Such campaigns increase knowledge of PrEP, and influence social and cultural attitudes. Health care workers must be trained and provided with materials on PrEP as prevention, and their training must be integrated with reproductive health services to reach women and speed the delivery of PrEP to everyone who needs it.

As Kenya again leads in HIV prevention, this time with PrEP, we cannot repeat the mistakes of the past, which seriously hampered the roll out of VMMC. The potential public health benefits are enormous. There must be a pragmatic approach of integrating existing HIV prevention efforts, especially PrEP, into broader sexual reproductive health services. Overall, increasing PrEP access and acceptance requires effort to make sure those most vulnerable to HIV—including adolescents, sex workers and MSM learn about PrEP and can get it in a safe, culturally sensitive and cost-effective manner.