Views of policymakers, healthcare workers and NGOs on HIV pre-exposure prophylaxis (PrEP): a multinational qualitative study

[This is of great interest to the Mapping Pathways team as our work is quite similar. Very interesting!]


via British Medical Journal, by Ana Wheelock, Andreas B Eisingerich, Gabriela B Gomez, Emily Gray, Mark R Dybul, Peter Piot

Abstract

Objectives To examine policymakers and providers' views on pre-exposure prophylaxis (PrEP) and their willingness to support its introduction, to inform policy and practice in this emerging field.

Design Semistructured qualitative interview study.

Setting Peru, Ukraine, India, Kenya, Uganda, Botswana and South Africa.

Participants 35 policymakers, 35 healthcare workers and 21 non-governmental organisation representatives involved in HIV prevention.

Results Six themes emerged from the data: (1) perceived HIV prevention landscape: prevention initiatives needed to be improved and expanded; (2) PrEP awareness: 50 of 91 participants had heard of PrEP; (3) benefits of PrEP: one component of the combination prevention arsenal that could help prioritise HIV prevention, empower key populations and result in economic gains; (4) challenges of PrEP: regimen complexity, cost and cost-effectiveness, risk compensation, efficacy and effectiveness, stigmatisation and criminalisation, information and training and healthcare system capacity; (5) programmatic considerations: user eligibility, communication strategy, cost, distribution, medication and HIV testing compliance and (6) early versus late implementation: participants were divided as to whether they would support an early introduction of PrEP in their country or would prefer to wait until it has been successfully implemented in other countries, with around half of those we spoke to supporting each option. Very few said they would not support PrEP at all.

Conclusions Despite the multiple challenges identified, there was general willingness to support the introduction of PrEP. Yet, strengthening existing HIV prevention efforts was also deemed necessary. Our results suggest that an effective PrEP programme would be delivered in healthcare facilities and involve non-governmental organisations and the community and consider the needs of mobile populations. Comprehensive information packages and training for users and providers would be critical. The cost of PrEP would be affordable and possibly segmented. Extensive counselling and innovative monitoring measures ought to be considered.

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PrEP's role in relationships

via Aidsmap, by Roger Pebody

Seeking to understand why adherence to pre-exposure prophylaxis (PrEP) was extremely high in a study of serodiscordant couples, qualitative researchers have found that trial participants saw PrEP as a way they could preserve their relationship despite the pressures created by the knowledge of different HIV status and the risk of infection.

In an article published online ahead of print last week in the Journal of Acquired Immunity Deficiency Syndromes, Norma Ware and colleagues also report that the support of study staff and of HIV-positive partners was crucial in supporting adherence.

Pre-exposure prophylaxis is a novel HIV-prevention strategy in which HIV-negative people take antiretroviral drugs before possible exposure to HIV, to lower the risk of infection.

Several studies suggest that PrEP is biologically efficacious. However, a major challenge for the real-world effectiveness of PrEP is that it relies on people who are not ill taking medication on a daily basis. Adherence has turned out to be less than perfect in some of the studies: for example, in the iPrEx trial of men who have sex with men, only around half actually took the drugs as prescribed.

However, adherence was significantly better in the Partners PrEP study, which recruited HIV-negative people who were in a stable heterosexual relationship with an HIV-positive person (i.e. they were in a ‘serodiscordant’ relationship), in Kenya or Uganda. Based on pill counts at the prescribing clinic, 97% of prescribed doses were taken. Based on unannounced pill counts at home, 99% of doses were taken. As a result, PrEP was more effective in this population.

In order to better understand why and how these near-perfect levels of adherence were achieved, Norma Ware and colleagues conducted in-depth interviews with 60 of the Partners PrEP trial participants in rural Uganda. Most interviews (45) were conducted with HIV-negative people taking PrEP, while 15 were with their HIV-positive partners. Just over half the participants were men, their average age was 35 and most had been study participants for over a year.

These were long-term relationships, with an average duration of just under ten years. Four out of five couples had children together. However, in most couples the HIV-positive partner was only diagnosed with HIV a few months before the PrEP study began.

Discovery that one partner was HIV-positive while the other was not created a crisis for most couples. HIV-negative partners felt hurt, angry and betrayed by the evidence of infidelity that infection represented to them, and threatened by the prospect of their partner’s imminent illness and premature death. Infected partners, for their part, feared “dying alone.”

Tensions developed, sometimes escalating into violence. Some relationships came close to fracturing under the strain.

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[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Uganda Needs to Re-Discover its Prevention Success of the 1990s

via AllAfrica.com, by Henry Zakumumpa

"The trouble for us in Uganda is that we are falling behind in global efforts to rein in new HIV infection rates an endeavor we were renowned for in the 1990s.

What is troubling is that many more people in Uganda are going to need AIDS treatment because of the spike in new HIV infections, driven primarily by married couples, but also because people with HIV/AIDS are now living longer, at a time when western donor countries are actually cutting AIDS funding.

Many AIDS treatment centres in Uganda are already turning away new patients due to donor funding caps, with some centres tragically sharing drugs amongst their patients. What is going to happen when thousands of Ugandans newly require AIDS treatment and they are turned away at treatment centres?

Sadly, Uganda's losing HIV prevention effort is out of step with the rest of the world where prevalence is actually going down. Even the worse- hit Southern African countries have registered a 25% reduction in HIV prevalence according to UNAIDS."

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[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]