Swazi Observer

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HIV PREP COULD BE GAME CHANGER IN HIV PREVENTION

By Samkelo Mahlalela | 2018-08-16

We are all familiar with the use of antiretroviral therapy (ART) as lifelong treatment of HIV in Eswatini since 2003.

Antiretroviral drugs (ARV) prophylaxis is also used to prevent HIV transmission from mother to child during pregnancy and the perinatal period.

Few, however, may know that ARVs are also used as a prophylactic intervention for HIV infection as standard clinical practice in the HIV response in the country.

They are commonly used as a 28-day course for post (after)-exposure prophylaxis (PEP) when either an occupational or a non-occupational exposure to bodily fluids has been determined.

Fast forward 30 years since the discovery of the HI virus, there is now ART for Pre (before, yes before) -exposure prophylaxis (PrEP) as a new prevention method.

In the past week, following news coming from the recently ended International AIDS Conference held in Amsterdam, Netherlands, local newspapers have featured prominently, the use of PrEP in Eswatini. Subsequently, many people may have been prompted to ask, what the big deal with PrEP is?

About PrEP

Well, in simple terms, PrEP is the use of ARVs by an uninfected person, prior to exposure to potential HIV acquisition.

Yes! These drugs are taken by HIV negative persons.

Since 2015, the World Health Organisation (WHO) has, recognised that PrEP has potential for population-wide benefits and thereby released guidelines and a policy brief recommending that PrEP be offered as a choice to people who are at substantially higher risk of HIV acquisition as part of a combination HIV prevention programme – having previously been recommended for only certain key populations such as sex (SWs) and men who have sex with men (MSM).

Trials have shown that, when taken consistently and correctly, PrEP is very effective and reduces the chances of HIV infection to near-zero – prompting some to refer to it as a ‘game changer’ for HIV prevention. PrEP reduces the risk of HIV infection through unprotected sex by over 90 per cent and more than 70 per cent for injecting drug use.

Eswatini has introduced oral PrEP, a daily course of ARVs tablets containing tenofovir/emtricitabine or Tenofovir/Lamivudine.

Though PrEP can provide very effective protection against HIV, it does not provide protection against other sexually transmitted infections (STIs) such as Hepatitis C, syphilis, and gonorrhoea, so there is still need for consistent and correct condom use. Also, the effectiveness of PrEP is closely linked to adherence - if someone taking PrEP regularly misses daily doses, their risk of HIV infection will increase substantially.

It is therefore important that any programme offering PrEP provides it as part of a combination package of prevention initiatives, based on an individual's circumstances - with support and advice on the importance of PrEP adherence.

The United Nations General Assembly’s 2016 Political Declaration on HIV and AIDS included a commitment to provide three million people at higher risk of HIV infection with PrEP by 2020.

However, by October 2016, there were just 100 000 people enrolled on PrEP, with the majority living in the USA. At present, oral PrEP is considered part of the PEPFAR HIV prevention toolkit, and procurement by PEPFAR is permitted in countries where: Test and start policies have been initiated; Viral load testing policies call for testing at least annually; and Multi-month ARV provision is available for stable clients.

This has seen the number and scope of PrEP activities increasing globally and Eswatini has not remained behind, with three demonstration projects of oral PrEP ongoing.

Oral PrEP demonstration projects in Eswatini

All 3 oral PrEP demonstration projects running in the country are for a period of 18 months.

These aim to answer the same key questions of acceptability and feasibility - with only one also looking at its cost effectiveness.

The projects are targeting anyone who is identified to be at higher risk using a risk assessment tool or who also perceives themselves to be at risk for HIV. People in substantial risk include those who have unprotected sex with a person with either known or unknown HIV positive status.

Priority groups and individuals include pregnant and lactating women, young women aged 16-25 years, sero-discordant couples (where one partner is living with HIV), MSM, SWs, and clients with STIs.

The demonstration projects assess who will be reached with an introduction to and an offer of PrEP, and who will take up the PrEP when as it becomes readily available through different delivery points in the public-sector health system, including: outpatient departments (OPD), antenatal care (ANC) services, postnatal care (PNC) services, family planning (FP), and following HIV counselling and testing services.

Currently, 45 per cent of those identified to be with substantial risk and clinically eligible have agreed to initiate PrEP -a larger proportion being females.

The difference between those eligible and those initiated is largely attributed to low awareness about PrEP and that clients need time to decide whether to initiate.

The 3 demonstration projects are:

n Expanding Options for HIV Prevention Through Pre-Exposure Prophylaxis in Hhohho Region, Eswatini - An observation cohort study with the overall aim to assess the operationalisation of oral PrEP in Eswatini as an additional HIV combination prevention method among population groups and individuals at high risk of HIV infection. Led by CHAI, the project targets the general population, with a minimum age limit of 16 years.

n Linkages Swaziland: Providing Access to HIV Pre Exposure Prophylaxis (PrEP) for those at high risk in Eswatini - This study offers PrEP to key populations and people at high risk of HIV infection through existing service platforms to determine whether it can be scaled up in a national programme. The population target is 18 years and above.

n MSF Swaziland PrEP Demonstration Project - This study is working to expand the evidence base related to the feasibility, acceptability, and tolerability of daily oral PrEP among key populations in Eswatini.

Eswatini’s inclusion in HPTN 084 Trial

The country has been included as one of six countries who will implement the long-acting injectable cabotegravir (CAB) for PrEP (classed under ARVs called intergrase inhibitors) as part of clinical trials of the HIV Prevention Trial Network (HPTN) 084.

The HPTN 084 is a phase three double-blind (meaning neither the participant nor research staff know what the participant is receiving) safety and efficacy study of CAB compared to the combination of daily oral tenofovir disoproxil fumarate 300 mg plus emtricitabine 200 mg (TDF/FTC) which will enrol sexually active women of childbearing age 18-49, non-pregnant and not intending to be pregnant until the project ends.

The HPTN study will test the safety and efficacy of injectable PrEP to prevent the acquisition and transmission of HIV.

The same drug has been investigated in the HTPN 077 study, where in enrolled 199 men and women at low risk of getting HIV at sites in Brazil, the US, Malawi and South Africa, with findings showing that a dose of 600 mg of cabotegravir administered consistently every eight weeks, is able to sustain appropriate levels in the blood stream in both men and women, is well tolerated and safe.

The injectable PrEP will offer an advantage over the oral drugs which could be tiresome as they are required to be taken daily.

Eswatini has one site (FLAS) that is expected to enrol a total of 148 female participants for a period of 12 months. This will be followed up by a follow-up period of four years.

No more need for

AIDS-related deaths

During the launch of the new multisectoral HIV National Strategic Framework, 2018-2023 in June this year, NERCHA’s Executive Director Khanyakwezwe Mabuza boldly stated that the country is fortunate to have available, many of the tools necessary to achieve zero-new infections in Eswatini.

As the multisectoral response, we wish all the projects to yield beneficial findings as we work to End AIDS by 2022.

For now, it is for me and you to choose life by taking an HIV test (with a screening test Self-test now available) then accessing related available services as per the outcome of thattest.

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